Pathology/Lab Coding Alert

Avoid this common CERT pitfall.

Perfect CPT^® and ICD-10-CM coding might not be enough to get your claims paid if your providers fail to adequately sign the medical records.

“Signature issues are among the biggest findings in the comprehensive error rate testing (CERT) and medical error rate programs, said NGS Medicare’s Gail O’Leary during the MAC’s recent webinar “Medicare Signature Guidelines.”

Here’s why: Medicare requires that services provided or ordered be authenticated by the author, and the method used for authenticating would be a handwritten or electronic signature, O’Leary said. Unsigned documentation or a lack of attestation will result in a claim denial, she noted.

To ensure that you successfully meet CMS’ signature guidelines and avoid denials, follow these five steps.

Step 1: Know When the Signature Itself Needs Support

In some cases, the provider will sign a document, but the signature isn’t legible. In these cases, you have the option of creating, maintaining, and submitting additional documentation to demonstrate that the signature belongs to the provider in question, which can include a signature log and/or an attestation.

“A signature log is a typed listing of the providers identifying their names with corresponding handwritten signatures. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation.”

Providers might also include an attestation statement. To be considered valid by Medicare, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

At any given time, you can submit an attestation statement, signature log, or a document affirming that the signature belongs to the provider if you find a signature to be illegible.

Step 2: Determine Who Must Sign

In most cases, the provider who performed or ordered the service will sign the record, but there are situations when coders have questions about who needs to sign. For instance, for an incident-to service, the record should be signed by the person who performs the service, not the supervising physician. However, the documentation must support evidence that the supervisor was present and available,” O’Leary said.

Step 3: Consider the Exceptions

As with most rules, some exceptions apply to the signature regulations, said NGS Medicare’s Lori Langevin during the webinar. The first exception, she said, is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

In addition, orders for clinical diagnostic tests need not be signed, but the treating physician must have medical documentation indicating that he or she intended the clinical diagnostic test to be performed, and that documentation must be authenticated by the author via a handwritten or electronic signature.

The third exception involves other regulations and CMS instructions regarding signatures – these can have priority over the standard regulations. “In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.”

The final exception indicates that CMS permits use of a rubber stamp for signatures in accordance with the Rehabilitation Act of 1973, which states that an author with physical disability must provide proof of their inability to sign due to their disability. In those cases, a rubber stamp would be permitted.

Step 4: Find out Which E-Signatures Work

If you’re wondering which types of e-signatures are acceptable from a Medicare standpoint, Langevin answered that by offering a few examples, as follows:

• “Reviewed by” with provider’s name
• “Released by” with provider’s name
• Chart “Accepted by” with provider’s name
• “Electronically signed by” with provider’s name
• “Verified by” with provider’s name
• “Signed before import by” with provider’s name
• Digitalized signature: Handwritten and scanned into the computer
• “Authorized by: John Smith, MD”
• “Digital Signature: John Smith, MD”
• “This is an electronically verified report by John Smith, MD”
• “Authenticated by John Smith, MD”
• “Confirmed by” with provider’s name
• “Electronically approved by” with provider’s name
• “Closed by” with provider’s name
• “Finalized by” with provider’s name

Step 5: Get the Rules on Amendments

Medicare requires you to document services in the medical record at the time of rendering, but in some instances, that isn’t always possible. If you realize after the fact that the documentation needs to be corrected, amended, or completed, you must ensure that your amendment is in line with Medicare’s amendment regulations.

Documents submitted to MACs containing amendments, corrections, or addenda must meet the following requirements, Langevin said:

1. Clearly and permanently identify any amendment, correction, or delayed entry as such

2. Clearly indicate the date and author, with signature, of any amendment, correction, or delayed entry, and original date of entry being corrected

3. Clearly identify all original content, without deletion.

“We’re not going to consider undated or unsigned entries handwritten in the margin of a document,” she said.