Why the New Signature Requirements Emphasis?
Find out how it began and what holds true for 2011.
By Lynn S. Berry, PT, CPC
Seemingly out of nowhere, providers have been barraged with material regarding Medicare signature requirements. Why is there a new emphasis on something that should be standard practice?
History in the Making
When the November 2009 Comprehensive Error Rate Testing (CERT) Improper Medicare Fee-For-Service (FFS) Payments Report was published, an astonishing result was noted. Although CERT errors had been falling steadily (from 10.1 percent in 2004 to 3.6 percent in 2008), there was a huge increase to 7.8 percent in 2009. Why?
Each year, the Office for Inspector General (OIG) conducts an audit of the CERT process and makes recommendations. Due to growing concern with Medicare fraud and abuse and a greater emphasis on government efforts to recover overpayments, the OIG performed a more extensive review in 2008 (especially of durable medical equipment (DME) payments) and, in 2009, conducted an independent review of 2008 CERT findings for all claim types. As a result of these audits, and based on the recommendations of the OIG, the Centers for Medicare & Medicaid Services (CMS) revised the error rate methodology for the 2009 report—instructing CERT contractors, among others, to “strictly enforce the Medicare policies.”
The 2009 CERT report subsequently concluded, “a significant portion of the new errors found in FY 2009 were due to a strict adherence to policy documentation requirements, signature legibility requirements, the removal of claims history as a valid source for review information, and the determination that medical record documentation received only from a supplier is, by definition, insufficient to substantiate a claim” [emphasis added].
Specifically, the following errors were found:
“Records from the treating physician not submitted or incomplete: In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.”
“Missing evidence of the treating physician’s intent to order diagnostic tests: In the past, CERT would consider an unsigned requisition or physicians’ signatures on test results. Now, CERT requires evidence of the treating physician’s intent to order tests, e.g., signed orders, progress notes.”
“Medical records from the treating physician did not substantiate what was billed: In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.”
“Missing or illegible signatures on medical record documentation: In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures.”
Subsequent to the CERT report, CMS published March 16 Transmittal 327, Change Request (CR) 6698, and MLN Matters article MM6698 Revised (www.cms.gov/transmittals), which outline rules for signatures and clarify how Medicare claims review contractors review claims and medical documentation. The transmittal identified contractors that must abide by the rules as Medicare claim review contractors (carriers, fiscal intermediaries (FIs), affiliated contractors (ACs), Medicare administrative contractors (MACs), the comprehensive error rate testing (CERT) contractor, and recovery audit contractors (RACs)).
The Current Rule in Effect
The current rule, outlined in CR 6698, specifies that any services provided or ordered must be authenticated by the author either by a hand written or electronic signature. A current exception to this is that orders for clinical diagnostic tests are not required to be signed; however, if not signed, there must be written evidence within the physician progress note or other such documentation containing the provider’s intent for the clinical diagnostic test to be performed. This must be authenticated by a handwritten or electronic signature.
CR 6698 gives further guidance for e-prescribing signature requirements and signature dating requirements. It also provides exceptions for hospice certifications and other requirements as specified by local coverage determinations (LCDs), national coverage determinations (NCDs), or Medicare manuals.
CR 6698 is retroactive for the November 2010 CERT reporting period (which includes the prior year). If you find you have illegible signatures in any 2009 or 2010 records requested by any Medicare review contractor, make sure a recent signature log is attached; if you find missing signatures, make sure an attestation statement is attached (see the Program Integrity Manual (PIM), publication 100-08, chapter 3, section 184.108.40.206 and 220.127.116.11, www.cms.gov/manuals, for detailed instructions).
Pages 430-437 of the proposed rule (www.federalregister.gov/inspection.aspx#special) provide a history of government rulemaking regarding signatures for clinical diagnostic tests and their reasoning for changing the current rule. The proposal now requires a physician or non physician practitioner (NPP) to sign requisitions for clinical diagnostic laboratory tests paid on the basis of the Clinical Laboratory Fee Schedule (CLFS) as a part of the other signature requirements.
CMS believes this will eliminate any confusion because a physician’s signature would be required for all requisitions and orders, thereby eliminating any uncertainty:
- Whether the documentation is a requisition or an order (a semantic issue)
- Whether the type of test being ordered requires a signature, or
- Which payment system (the MPFS or CLFS) requires a physician or NPP signature.
CMS also says the proposed rule would make it easier for the reference laboratory technicians to determine whether a test has been requested appropriately. Potential compliance issues would be eliminated during any subsequent Medicare audits because a signature would always be required.
What This Means for 2011
If the proposed rule goes into effect, as of Jan. 1, 2011, every piece of documentation written by the physician or NPP, including any orders or prescriptions, must have an authenticated, legible signature. This includes any orders or requisitions for clinical diagnostic tests, as well as initial notes, progress notes, daily logs, or any other document in the medical record. You should include a printed name under the physician’s signature so it is clear who wrote the document or signed the order.
CR 6698 and the regulations in chapter 3, section 18.104.22.168 and 22.214.171.124 of the PIM clearly define a legible, authenticated signature for Medicare. It cannot be a stamped signature and or an electronic signature for prescribing narcotics (this last requirement may change). CR 6698 outlines how the provider can appeal a ruling based on signature logs and attestation statements.
Make sure your physician and/or NPP understands these regulations. This should help the CERT rate to go back down, reduce the possibility of fraud and abuse, eliminate any threats regarding this issue from MACs, CERT, or RACs, and reduce appeals on the part of the provider—thus improving your bottom line.