New Signature Guidelines in Effect
New signature guidelines for medical review purposes went into effect April 16. Medicare requires all services provided/ordered be authenticated by the author. In general, signature stamps are out; handwritten or electronic signatures are in.
Reviewers are instructed to disregard an entry with a missing or illegible signature, and make the claims review determination based only on authenticated documentation. To ensure proper payment, providers can include a signature log or an attestation statement in the documentation.
A signature log identifies the author associated with initials or an illegible signature. An attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.
The Centers for Medicare & Medicaid Services (CMS) provides an example of an attestation statement in Transmittal 327, Change Request (CR) 6698, issued March 16.
Update: All signature requirements in CR6698 are effective retroactively for Comprehensive Error Rate Testing (CERT) for the November 2010 report period.
Exceptions to the Rule
Stamp signatures are no longer acceptable, with the following exceptions:
- Facsimiles of original written or electronic signatures for terminal illness for hospice
- Clinical diagnostic test orders, which do not require a signature (but do require authenticated documentation)
- In cases where the relevant regulation, National Coverage Determination (NCD), Local Coverage Determination (LCD), and Medicare Claims Processing Manual have specific signature requirements, those take precedence
Electronic prescribing naturally calls for electronic signatures. Medicare Part B drugs other than controlled substances do not require hardcopy signatures. Controlled substances, however, still do “at this time.”
For more information regarding signature requirements, see MLN Matters No. MM6698 and JA6698.