Health Information Management

Tip: Audit records for signature documentation

CDI Strategies, September 2, 2010

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CMS requires that orders for healthcare services be authenticated using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication and previous language in the CMS Program Integrity Manual required a “legible identifier.”

Earlier this year, however, CMS Transmittal 327 added additional clarification and signature assessment requirements aimed at the agency’s various contractor reviewers (i.e., MACs, CERTs, and RACs). In the transmittal, CMS says reviewers need to monitor the signature authentication process if the reason for a denial is a missing signature or an illegible signature. In that instance, the reviewer must follow a specific signature assessment protocol.

For example, if the signature is missing from an order, CMS says the reviewer should disregard the order during the review of the claim. If the signature is illegible, the reviewer can request a signature log or attestation statement to determine the identity of the author of a medical record entry.
 
CMS also indicated that:
  • If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry.
  • Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process.
  • Other providers in the same group may not attest to the original author’s signature.
  • If the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. (For example, if the reviewer finds that the first and third orders on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date.)
Although CMS directed its transmittal to its contractors, CDI specialists can play a role in helping to ensure all documentation includes appropriate dates and signatures. If an order is not signed the reviewer is instructed to disregard it. In other words, without an order, the service did not occur.
Editor’s Note:Debbie Mackaman, RHIA, CHCO, an instructor for HCPro’s Medicare Boot Camp®—Hospital Version, based in Marblehead, MA, provided this tip in the Medicare Mentor Blog.



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