Podiatry Coding & Billing Alert

Hint: You must heed certain guidelines for electronic signatures.

Understanding Medicare’s signature guidelines can seem tricky at times. The Medicare Administrative Contractive (MAC) National Government Services (NGS) recently held a webinar to help clear up some of the many questions you may have about signature requirements.

Read on to learn helpful signature tips and keep your claims in tip-top shape.

Tip 1: Check Signatures For Validity

A valid signature should meet the following requirements, according to Lori Langevin, NGS provider outreach and education consultant:

• The ordering physician authenticated the services that he provided or ordered.
• The signature is legible. (If the signature is illegible, you can submit a signature log or attestation statement).
• The signature is handwritten, electronic, or stamped (a special exception).

Don’t miss: You should only use a stamped signature as a very special exception. CMS permits use of a rubber stamp for a signature in accordance with the Rehabilitation Act of 1973, according to Gail O’Leary, NGS provider outreach and education consultant.

“Stamped signatures are only permitted in the case of an author with a physical disability who can provide proof of an inability to sign due to a disability,” Langevin explains. By affixing the rubber stamp signature, the provider certifies that they have reviewed the document.

Tip 2: Take Certain Steps If Signature Not Legible

You have a couple of options if you notice that your physician’s signature isn’t legible — a signature log and an attestation statement.

If you are gathering medical documentation, and you notice the signature is illegible, please go ahead and include an attestation statement or signature log from the provider or physician that affirms the signature is the provider’s, O’Leary says. Don’t wait for your MAC to request the signature log or attestation.

Signature log defined: “A signature log is a typed listing of the provider or providers identifying their name with a corresponding handwritten signature,” O’Leary says.

You must also include the credentials associated with the initials or the illegible signature, O’Leary adds.

Don’t miss: You may include the signature log on the same page where the initial or illegible signature is located or in a separate document, O’Leary says. Just make sure that the signature log is a part of the patient’s medical record.

There can be an individual log consisting of one person or a group log consisting of all the doctors in the entire practice, O’Leary adds.

Attestation statement: You can also submit an attestation statement if the provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, according to O’Leary.The statement must also include the appropriate patient information.

Tip 3: Heed These Guidelines For Electronic Signatures

If your provider uses electronic signatures, you must make sure they meet the following certain criteria, according to Langevin:

• Rule 1: The systems and software your office uses must be protected against modification.
• Rule 2: Your administrative safeguards should follow standards and laws.
• Rule 3: Teach your office that whoever’s name in on the alternate signature method and the provider are taking responsibility that the attested info in the medical record is true.
• Rule 4: Include a copy of your office’s electronic signature protocol procedure.

Note: This protocol procedure for electronic signatures should just describe the requirements that the physician uses such as that they use their own ID and password to enter it into the system, Langevin says.

You should never have to supply your actual user IDs and passwords, Langevin adds. Just what your protocol is.

Tip 4: Handle Amendments and Corrections Like This

If you ever have a case where you must deal with amendments, corrections, or delayed entries in the medical documentation, you must make sure that your practice heeds certain recordkeeping principles, says Langevin. Any document you submit to your MAC should “clearly and permanently identify any amendment, correction, or delayed entry as such.”

You also want to make sure that you clearly mark the date and the author of any amendment, correction, or delayed entry, as well as the original date of the entry you are correcting.

And, you should clearly identify the original content of the record, without deletion. This is very important, Langevin says. You should never delete anything from a medical record.

Paper medical records: In the case of a paper medical record, you can perform a correction by using a single line to strike through the content. Make sure the original content is still legible. And, the person who makes the alteration to the record should sign and date it.

Electronic health records: For electronic health records (EHRs) that contain amendments, corrections, or delayed entries, you must make sure that they distinctly identify the amendments, corrections, or delayed entry, according to Langevin. The original content, modified content, and date and authorship of each modification in the record must also be clearly identified.