Health Information Management

News: CMS Transmittal focuses on physician signatures

CDI Strategies, March 18, 2010

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For CDI specialists, the physician signature is one more critical piece of documentation to keep an eye on. Actually, it’s one of primary reasons to query the physician according to the AHIMA physician query practice brief, “Managing an Effective Query Process”.
CMS Transmittal 326 (Change Request 6698) released March 16 reiterates the fact that physicians need to sign and date orders for service in a legible manner or else risk an auditor’s ire and claims denials.
The transmittal states the following: “For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable.”
To resolve the problem of illegible signatures, many facilities actually handed out stamps with physicians’ names on them requiring them to be used for signing their orders and/or progress notes says Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Coordinator for HCPro, Inc., in Marblehead, MA. If that’s still the case many facilities will need to change how they obtain physician signatures.
Note that there are some exceptions to the rule. For example, this requirement does not cover physician orders on diagnostics tests performed during inpatient stays. As long as the request for services is documented in the physician’s notes and is authenticated with the physician’s signature, a specific order signed by the physician isn’t required, according to the transmittal.
Essentially, the transmittal offers guidance to government contractors who review claims and medical documentation submitted by providers. It outlines when they should deny claims due to insufficient or missing signatures, what substitute documentation they can accept, and how they should proceed.
To download a copy of the transmittal, visit the CMS Web site.  

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