Health Information Management

Take note of signature requirements to ensure compliance when coding for labs and diagnostic testing

JustCoding News: Outpatient, August 11, 2010

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by Holly J. Cassano, CPC

Providers must understand the revisions to signature guidelines outlined in MedLearn Matters article 6698 and Transmittal 327 in the Medicare Program Integrity Manual, which were revised on April 26 to include additional clarifying language from CR 6698 and are retroactive to March 1 in order to satisfy the November 2010 reporting period.

Let’s take a closer look at the updated provider signature guidelines for labs and diagnostic testing.

These guidelines affect physicians, nonphysician practitioners, and suppliers submitting claims to Medicare fiscal intermediaries (FI), Part A/B Medicare administrative contractors (MAC), carriers, Recovery Audit Contractors (RAC), regional home health intermediaries, and durable medical equipment (DME) MACs for services provided to Medicare beneficiaries, according to MedLearn Matters article 6698.

Note exceptions to signature guidelines

Prior language from the Program Integrity Manual stipulated that a legible identifier was required from the ordering provider, either in handwritten or electronic signature form, for every service provided or ordered.Transmittal 327 in the Medicare Program Integrity Manual updated these requirements and added e-prescribing language. Also, a stamped signature is no longer acceptable. However, there are several exceptions to the outlined guidelines:

  • Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
  • Signatures for clinical diagnostic test orders are not required, but there must be medical documentation by the treating provider (e.g., a progress note) showing the intent that the test be performed. Also, the author must authenticate this via a handwritten or electronic signature.
  • Other regulations and CMS instructions regarding signatures (e.g., timeliness standards for particular benefits) take precedence. For medical review purposes, when the relevant regulation, national coverage determination (NDC), local coverage determination (LCD), and CMS manuals are silent on whether the signature be legible or present and the signature is illegible or missing, the reviewer should follow the guidelines listed below to discern the identity and credentials (e.g., MD or RN) of the signing party. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.

Learn what signature variations that meet requirements

CMS is very specific in the new guidelines as to what it recognizes as a valid signature. The following examples of signatures highlight what CMS will allow under the rules.

Handwritten signature. A handwritten signature could be a mark or signature by an individual on a document to signify knowledge, approval, acceptance, or obligation.

The following handwritten signature examples meet the requirement:

  • Legible full signature
  • Legible first initial and last name
  • Illegible signature over a typed or printed name

There are also some examples of acceptable illegible signatures that sufficiently indicate the identity of the signator. For example, an illegible signature may appear on a prescription. The prescription letterhead may list three physicians along the top, with one of the names circled. This meets physician signature requirements.

However, if a physician provides an illegible signature, but it does not appear over a typed/printed name and he or she does not submit it with a signature log or an attestations statement, this would not satisfy physician signature requirements.

Electronic signature. Providers using an electronic system must understand the propensity for misuse or abuse with the availability of alternate signature methods. They will have to ensure that the electronic medical record (EMR) or other software product they are using has adequate protection against modifications once a provider has electronically signed off on a record.

An electronic signature acts a footprint from a compliance standpoint, and that provider of record is authenticating the services provided by signing the note electronically. The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information to which they are attesting.

For example, Dr. White is a Fellow at Century Hospital and is rounding with his attending, Dr. Smith. They both go in to see the patient, and Dr. White “scribes” the note for Dr. Smith in the EMR. Dr. White puts his electronic signature on the record and states that he scribed the note for the visit for Dr. Smith. Then Dr. Smith has to go into the EMR and “close” the note that Dr. White scribed and attest that he, Dr. Smith, is the one who examined the patient for the actual visit, not Dr. White. However they both are responsible for the information provided in the EMR.

Signature log. In the documentation, providers will sometimes include a signature log that identifies the author associated with initials or an illegible signature. The signature log might be included on the same page where the initials or illegible signature appear or might be a separate document. Reviewers will consider all submitted signature logs regardless of creation date.

For example, Dr. Green rounds on patient A in the hospital after surgery. Dr. Green generates a progress note subsequent to his progress note from the day before on patient A. Dr. Green signs with an illegible signature in addition to several initialed dates of service. Several days later, a comprehensive error rate testing (CERT) auditor requests the records for review. Because the physician’s signature is illegible, the physician of record provides a signature log, which includes his printed name, his full signature, and initials that appear on the document. Dr. Green also lists his credentials for further proof and validation.

To view a sample signature log, access the American Academy of Family Physicians website.

Attestation Statement. To be valid for Medicare medical review purposes, the author of the medical record entry must sign and date the attestation statement, which must contain the appropriate beneficiary information.

Click here to see an example of an acceptable attestation statement from MLN Matters article 6698.

Understand when coders need to verify signatures

Regardless of specialty, most coders will at some point need to review a medical record and verify that there is a proper signature from the ordering provider when certain tests or drugs are relevant for code assignment.

For lab services, providers’ offices often fax orders ahead of time or patients will present with the actual orders. 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 provider (e.g., consulting physician, nurse practitioner, clinical nurse specialist, or physician assistant permitted by state law to order diagnostic tests). The document may be hand delivered, mailed, or faxed to the testing facility.
 

Transmittal 327 states there are circumstances in which a provider does not need to sign an order (e.g., clinical diagnostic tests). However, when 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 to be performed. He or she must also authenticate this notation by a handwritten signature or e-signature.
In a retrospective MAC or RAC audit , for example, the auditing party can request monies back if it determines that the documentation is unsatisfactory and outside of the new guidelines.
Consider MAC and MedLearn guidance


TrailBlazer Health Enterprises, LLC, provided the following guidance in July for documentation requirements:

The ordering physician must maintain documentation of medical necessity in the beneficiary’s medical record. The laboratory must maintain the documentation it receives from the ordering physician and must ensure the information listed on the claim accurately reflects the documentation it received from the ordering physician.

However, Medicare does not require the ordering physician’s signature on a laboratory service requisition. While the physician’s signature on a requisition is one way of documenting that he or she ordered the service, it is not the only permissible way of documenting that the physician ordered the service. For example, the physician may document in the medical record that he or she ordered specific services.

Consider the following June 14 MedLearn.com Q&A related to lab tests:

Question: When a prescription is missing one or more of the five requirements (specifically diagnosis code or physician signature) and you cannot contact the office for a verbal or fax (in the case of a missing signature), do you send the patient away to have them get a corrected prescription or have them wait until the correct information can be obtained?

CMS’ Medlearn Answer: The order needs to be a valid order to carry out the services. We realize that there are times in which an order may not be complete, and the facility would like to carry out the service or test and get the missing information after the fact. However, this is not what Medicare and other third-party payers want. What they want is a complete and valid order in place to execute the service. There also may be some implications from state licensure and/or the Joint Commission for doing it differently.

MedLearn Suggestions: Create a fax-back form that you send to the physician's office and, hopefully, get it returned in a timely manner. Before you send the first fax, be sure and let your physicians know that you are implementing this process because of incomplete orders. Also, help educate the physicians on what is needed on the order. If the order is sent over ahead of time, there is usually time to correct the missing information. If the patient brings the order with him or her, this is where we need a fax back form if the order is not complete.

Note the following May 17 MedLearn Q&A:

Question: Would it be acceptable to order tests on patients during preadmission testing based on the patient's history without an order from a physician?

CMS MedLearn Answer: It is not acceptable for the laboratory to perform any testing without a physician's order or to use a patient's history as the reason for testing. Laboratory tests can only be performed when there is a written request from an "authorized person," a licensed health professional performing within the scope of his or her state license. This is a Clinical Laboratory Improvement Amendments regulation. Providers who order tests must provide the laboratory with the reason for testing at the time the test is ordered.

CMS has provided the following guidance to affiliated contractors, MACs, RACs, CERT, Program Safeguard Contractors, and Zone Program Integrity Contractors reviewers for applying signature requirements:

  • Providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process. Generally 24–72 hours is the typical turnaround time for the provider transcription process. Instead providers may employ the signature authentication process.
  • When the signature is illegible, auditing parties shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
  • When the signature is missing from an order, auditing parties shall disregard the order during the review of the claim.
  • When the signature is missing from any other medical documentation, auditing parties shall accept a signature attestation from the author of the medical record entry.
     

To maintain compliance, providers must be diligent and implement measures to ensure that they are in compliance with the new signature guidelines so that they have sufficient documentation to support the services provided and to avoid potential requests for refunds if a contractor is unable to validate the provider signature on a record. To keep their dollars and avoid unnecessary inquiries, providers should implement an active validation process.

Editor’s note: Holly Cassano, CPC, is a medical coder, educator, and auditor for the Emergency Department and Bariatric Center at the Cleveland Clinic in Weston, FL. E-mail her at hjcpmg@yahoo.com



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