One of the new sections in Transmittal 327, issued March 16, relates to additional documentation requests (ADRs) and signature requirements.
In part I of Section 188.8.131.52, CMS directed comprehensive error rate testing (CERT) contractors to use language in their ADR letters reminding providers that they may need to contact another entity to obtain the signed version of a document.
For example, a hospital discharge summary in a physician's office files may be unsigned, but the version in the hospital's files may be signed and dated. In such a case, physician office staff would need to contact the hospital where the physician provided the service and obtain signed progress notes, a plan of care, discharge summary, etc.
While CMS tells CERT contractors that they "shall" do the above, making it mandatory, it merely "encourages" such language from other contractors, including fiscal intermediaries and Medicare administrative contractors (MACs).
CMS has urged payers to direct providers to review their documentation prior to submission in order to ensure that all services and orders are signed appropriately. However, when a reviewer notices a note with a missing or illegible signature, providers may be informed that it's appropriate for them to submit a signature log or signature attestation as part of their ADR responses. In fact, when the providers themselves question the legibility of a signature on documentation, they proactively may submit an attestation statement.
ADR letters from payers also may remind providers that submitted documentation must include the following: patient identification, date of service and provider of the service.
If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing or illegible signature. This could lead to a decision that the medical necessity for the service billed has not been substantiated.
Little wonder interest continues to grow on this crucially important subject.
About the Author
Randy Wiitala, BS, MT (ASCP) is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.
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