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New CMS Signature Regulations Baffle Providers
By Cheryl Servais, MPH, RHIA

The Centers for Medicare & Medicaid Services (CMS) recently issued two publications indicating the organization is tightening its requirements for signatures on prescriptions and orders for services.

The impetus behind the decision is the November 2009 Comprehensive Error Rate Testing (CERT) report. The latest error rate reported by the Hospital Payment Monitoring Report Program and the CERT program nearly doubled from 3.7% to 7.8%. One major factor contributing to this higher rate was missing or illegible signatures. Concerning missing or illegible signatures on medical record documentation, the report states, “In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures. Now, CERT disallows entries if a signature is missing or illegible.”

The CMS has instructed CERT contractors to follow the letter of the law to identify correct and legible signatures on documentation supporting provided services for which bills have been created.

Further details related to signatures were published in Transmittal 327 for the Medicare Program Integrity Manual (100-08) released March 16. The signature guidelines apply to reviews conducted by Medicare administrative, CERT, and recovery audit contractors.

What Is an Acceptable Signature?
Effective April 16, as indicated in Transmittal 327, “Medicare requires that services provided/ordered be authenticated by the author.”

Acceptable methods for handwritten signatures are as follows:
• a legible full signature;
• a legible first initial and last name
• an illegible signature over typed or printed name;
• an illegible signature where letterhead, addressograph, or other information indicate the author’s identity;
• an illegible signature accompanied by signature log or attestation statement (see below);
• initials over a printed or typed name; and
• initials accompanied by a signature log or attestation statement (see below).

Acceptable methods for e-signature are an e-mail by the treating physician/practitioner or his office to the testing facility and an unsigned note where other entries on the same page in the same handwriting are signed.

Unacceptable signature methods are as follows:
• rubber stamp signatures except for certifications of terminal illness for hospice care and orders for clinical diagnostic tests;
• illegible signatures with no additional documentation to identify the signature;
• initials with no additional documentation identifying them;
• an unsigned note; and
• a note with the statement “signature on file.”

For signatures on clinical diagnostic tests, including diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary, an order may include a written document signed by the treating physician (consultant or treating physician)/practitioner (nurse practitioner, clinical nurse specialist, or physician assistant who may, by state law, order diagnostic tests). The document may be hand delivered, mailed, or faxed to the testing facility.

In the case of a telephone call by a treating physician/practitioner or his or her office to a testing facility, both parties must document the communication in their respective copies of the beneficiary’s medical records.

The transmittal states there are circumstances in which an order does not need to be signed (eg, clinical diagnostic tests). However, if the order is unsigned, the treating physician must include documentation, such as a progress note, that indicates he or she intended the clinical diagnostic test be performed. This notation must be authenticated by a handwritten or e-signature.

It must be noted that the Medicare Conditions of Participation have specific rules in the Medical Records section concerning the authentication of orders that seem to differ from the requirements of Transmittal 327. For example:

• Section 482.24(c)(1)(i): This provision requires that all orders, including verbal, be dated, timed, and authenticated promptly by the ordering practitioner, except as noted in subsection (ii). One minor revision has been made in the final rule based on public comment. The word ordering has replaced the word prescribing. Otherwise, the standard is being finalized as proposed.

• Section 482.24(c)(1)(ii): This provision permits a temporary exception to the requirement that all orders, including verbal ones, be dated, timed, and authenticated by the ordering practitioner. For a period of five years beginning with the effective date of this final rule (January 26, 2007), verbal orders will not need a signature from the ordering practitioner but could be authenticated by another practitioner responsible for a patient’s care. One minor revision has been made in this final rule based on public comment: The word ordering has replaced the word prescribing. Otherwise, the standard is being finalized as proposed.

• Section 482.24(c)(1)(iii): This provision specifies that all verbal orders must be authenticated based on federal and state law. If there is no state law designating a specific time frame for the authentication of verbal orders, then they must be authenticated within 48 hours. This standard has not been revised and therefore is being finalized without change.

The transmittal goes on to state that “other regulations and CMS instructions regarding signatures (such as timeliness standards for particular benefits) take precedence.” So it would seem that a verbal/telephone order must be authenticated within 48 hours (unless state standards require a different time frame).

Signature Logs
The signature log will include the typed or printed name of the caregiver authorized to sign an order or a notation together with a copy of the initials and/or illegible signature. It can be included on the actual page where the initials or illegible signature are used or it may be a separate document. Providers should list their credentials in the log, but a claim will not be denied for missing credentials.

Attestation Statements
The CMS states that providers should not add late signatures to a medical record (beyond the short delay that occurs during the transcription process). Instead, they should use the signature authentication process, which requires the author to sign an attestation that he or she is the originator of the order. This process does not allow for anyone but the ordering/treating physician to make the attestation. While there is currently no specified format or language for the attestation, a suggestion is included in the transmittal.

The CMS instructs reviewers not to consider attestation statements signed by someone other than the author of the medical record entry even if the two individuals are in the same group (one cannot sign for the other). Reviewers must consider all properly worded and signed attestations, regardless of the date, unless regulations require a signature prior to provision of services (eg, a care plan).

— Cheryl Servais, MPH, RHIA, is vice president of compliance and privacy officer at Precyse Solutions.