Disclaimer. presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created.

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1 Change Request 6698: Signature Requirements for Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach and Education June 10, 2010 Disclaimer This resource isnot a legaldocument. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 2 1

2 Topics Change Request 6698 Signature Requirements for Comprehensive Error Rate Testing (CERT) CERT and Signatures CMS and Cahaba GBA Resources 3 What s New: Change Request 6698 Signature Requirements for Transmittal 327 Change Request (CR) 6698 Effective Date: March 1, 2010 Release Date March 16, 2010 Implementation Date: April 16, 2010 Re issued Date April 26, 2010 MLN Matters Number: MM

3 Signature Requirements 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. Program Integrity Manual 100 8: Chapter 3, Section B Transmittal 327: Change Request Signature Requirements Exception 1: Facsimile of original written or electronic signaturesare are acceptable for the certifications of terminal illness for hospice. Exception 2: Orders for clinical diagnostic tests are not required to be signed. If an order for a clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g. a progress note) that he/she intended the clinical diagnostic test be performed. Intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. 42 CFR 410 and Pub , Benefit Policy, Chapter 15, Section Transmittal 327: Change Request

4 Signature Requirements Exception 3: For medical review purposes, if the NCD, LCD and CMS manuals are silent on whether the signature be legible or present and the signature is illegible/missing, the reviewer shall follow the new signature guidelines to discern the identity and credentials (e.g.md, RN) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence. 7 Signature ignatu e Requirements for Medical Review Purposes 4

5 What Are We Looking for in Your Medical Records? Medical Necessity Social Security Act 1862(a)(1)(A): All billed services must be based only on activities that are reasonable and necessary for the diagnosis or treatment of illness or injury. Program Integrity Manual, Chapter 3, Section : CMS can request records for review to make a prepayment or postpayment claim review determination. 9 Handwritten Signature Medicare s Signature Definition A handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation. 10 5

6 Signature Log A signature log lists the typed or printed name of the author associated with initials or an illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document. Reviewers may encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials. Reviewers shall consider all submitted signature logs regardless of the date they were created. 11 Timeliness of Signatures Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead may make use of the signature authentication process. 12 6

7 Signature Dating Requirements For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the reviewer shall review to ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered. d 13 Signature Dating Requirements EXAMPLE: The record showed a hospital visit on October 4. The Facility respondedto the Additional Documentation Request (ADR) and submitted a one page note from the hospital medical record containing three entries. The first entry is dated October 4 and is a physical therapy note. The second entry is a physician visit note that is undated. The third entry is a nursing note dated October 4. The reviewer may conclude that the physician visit was conducted on October

8 Handwritten Signature Points Illegible signature: a signature log or attestation statement is considered to determine the identity of the author of a medical record entry. If a signature is missing from an order, the contractor shall disregard the order during review of the claim. A signature attestation letter is acceptable from the author, if a signature is missing from any other medical documentation. 15 Signature Attestation Statement An attestation statement must be signed and dated by the author of the medical record entry and; An attestation statement must contain sufficient information to identify the beneficiary. An attestation statement must have documentation that is associated with the medical record entries and the author of record in question. In cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements. Reviewers will consider all attestations that meet the guidelines regardless of the date the attestation was created, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date. 16 8

9 Signature Attestation Statement CMS is neither requiring nor instructing providers to use a certain form or format. Providers may choose to use this CMS example for an attestation letter: I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. 17 Signature Requirements Reviewers will conduct the following, in situations where the guidelines indicate: Signature requirements met the entry is considered. Contact the provider and ask a non standard follow up question Reviewer will contact the provider or organization that billed the claim and ask if they would like to submit an attestation statement or signature log within 20 calendar days. The 20 day timeframe begins with the actual phone contact with the provider or on the date the request letter is received at the post office. Providers will not be contacted for reasons unrelated to signature requirements. Signature requirements NOT met the entry is disregarded and the medical review determination is made using only the other submitted documentation. 18 9

10 Signature Requirement Chart Signature Requirement Met 1 Legible full signature X Contact billing provider and ask a non-standardized follow up question 2 Legible first initial and last name X 3 Illegible signature over a typed or printed name X Example : John Whigg, MD 4 Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signator. X Example: An illegible signature appears on a prescription. The letterhead of the prescription lists 3 physicians names. One of the names is circled. 5 Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by: X 1) a signature log, or 2) an attestation statement CR Signature Requirement Chart 6 Illegible Signature NOT over a typed/printed name, NOT on letterhead and the documentation is Signature Requirement Met Contact billing provider and ask a non-standardized follow up question UNaccompanied by: Illegible Signature NOT over a typed/printed name, NOT on letterhead and the documentation is UNaccompanied by: X a) a signature log, or b) an attestation statement Example: CR

11 Signature Requirement Chart Signature Requirement Met Contact billing provider and ask a non-standardized follow up question 7 Initials over a typed or printed name X 8 Initials NOT over a typed/printed name but accompanied by: a) a signature log, or b) an attestation statement X 9 Initials NOT over a typed/printed name UNaccompanied by: a) a signature log, or b) an attestation statement X CR Signature Requirement Chart Signature Requirement Met Contact billing provider and ask a non-standardized follow up question 10 Unsigned typed note with provider s typed name X Example: John Whigg, MD 11 Unsigned typed note without providers typed/printed name 12 Unsigned handwritten note, the only entry on the page X X 13 Unsigned handwritten note where other entries on the same page in the same handwriting are signed X 14 signature on file X CR

12 Electronic Signatures Providers should recognize the potential for misuse or abuse in using alternate signature methods. Make sure you have a system and software products which are protected against modification. Apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information attested to in the medical record. Physicians are encouraged to check with legal representation in regard to the use of alternative signature methods. 23 Physician s Signature Happy Clinic Name: Ducky, Don Sex: M Room#: 111 Admitting Physician: John Doe, M.D. Page 1 Medical Documentation John Doe, M.D. I authorize my name to be automatically affixed to this report, signifying I have dictated this report and reviewed it accordingly. TJ/TJ DD: 10/02/ :25:14 DT: 10/02/ :47:

13 Physician s Signature 10/20/08 Medical Center Hospital ED Physician: Doe Physicians Notes Patient Name: Janie Ducky Date of Service: 1/016/08 Date of Birth: 01/01/30 Age: 80 Sex: Female Chart # Medical Documentation Digitally signed by Dr. Doe, John on Friday, October 17, 2008 at 21:34 Condition: i Stable Diagnosis: Hypertension, Acute Headache CPT Codes: These notes were digitally signed by John Doe, MD on Friday, October 17, 2008 at 21:34 Physician: John Doe, M.D. 25 Electronic Prescribing Electronic prescribing (e prescribing) is the transmission of prescription or prescription related information through electronic media. E prescribing takes place between a prescriber, dispenser, pharmacy benefit manager (PBM), or health plan (directly or through an e prescribing network). A valid order for any Part B drugs, other than controlled substances, is acceptable through a qualified E Prescribing system. Part B drugs, other than controlled substances, ordered through a qualified E Prescribing system, hardcopy pen and ink signatures are not required for review. For controlled substances, reviewers shall only accept hardcopy pen and ink signatures as evidence of a drug order. For Medicare Part B medical review purposes, a qualified E Prescribing system is one that meets all 42 CFR requirements. To review the official standards for electronic prescribing, 42 CFR Standards for Electronic Prescribing, you may go to on the Internet

14 Comprehensive Error Rate Testing (CERT) The CERT Program Protect tthe Mdi Medicare trust tfund Measure Medicare s ability to pay claims correctly Assess provider behavior Evaluate contractor behavior Stamp signatures are not acceptable Documentation can be submitted electronically on a CD, mailed or faxed May appeal to Cahaba GBA 27 For more information, visit these websites: Common Medical Record Errors Signature errors Signatures are illegible or no identifying signature of who provided the service. Stamped signatures. No physician signature after PA or CRNP signed. Medical Necessity Errors / Insufficient Documentation Services were not medically necessary. Documentation did not include DOS, name of beneficiary, or legible identity of performing provider. Progress notes not signed. Electronic records with no electronic signature and no typed signature (check with vendor regarding printing e records). Incorrect Coding of Evaluation and Management Services E&M services up coded; medical records do not support the level of E&M service billed

15 PART A CERT SIGNATURE ERRORS 29 Part A CERT Reports November 2009 report resulted in increases in error rates due to: Medical necessity errors = 65% Medical necessity was not validated by physician signatures or documentation. Errors also showed no signed physician orders for laboratory services and diagnostic tests

16 Part A CERT Reports November2009 report showed missing evidence of the treating physician's intent to order diagnostic tests: In the past, CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, e.g., signed order or progress notes. 31 PART B CERT SIGNATURE ERRORS 32 16

17 Part B CERT Reports November 2009 CERT feedback files indicated a significant increase in errors due to missing or illegible signatures and missing physician orders affecting all type of services. CERT errors: 36% for insufficient documentation, 59% of the 36% were errors due to signature issues. CERT errors also showed no signed physician orders for laboratory services and diagnostic tests. 33 Part B CERT Reports November 2009 CERT feedback files: Although Evaluation and Management Services continues to contribute to the largest amount of dollars in error, Radiology, Pathology, and Lab services increased due to a lack of signature and or orders. Radiology services contributed to approximately 89% of CERT errors A lack of signatures and or orders contributed to 91% of CERT errors 34 17

18 Signature Requirements: Tips Sign your medical records: Legible hand written or electronically signed. Do not use a stamp signature. Conduct self audits of your records before submitting for review. The reviewers look for documentation of intent in the physicians progress/office notes (e.g. signed order or progress note that a diagnostic test was performed). Make sure hand written or electronic office records submitted for review are signed; check with vendor to assist with printing E record with ihsignature, if needed. d Physicians must countersign notes, when applicable (nurse practitioner, physician assistant, etc., all working under physician direction). Facsimile of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice. 35 Signatures: Ambulance Providers CMS Beneficiary Signature Requirements Medicare Benefit Policy Manual Chapter 10: There must be an appropriate beneficiary signature for accepting assignment and submitting a claim. Documented medical necessity for transports. Submit medical records for review when requested

19 References New CMS Home Page web site: Change Request 6698: Signature Guidelines for : Effective Date: March 1, 2010 Implementation Date: April 16, &sortByDID=2&sortOrder=descending&itemID=CMS &intNumPerPage=10 Re issued April 26, 2010: MLN Matters Number: MM6698 Revised Related to Change Request (CR) 6698: Program Integrity Manual Pub Chapter: B: Documentation Specifications for Areas Selected for Prepayment or Post payment MR: 99&sortByDID=1&sortOrder=ascending&itemID=CMS019033&intNumPerPage=10 CMS YouTube Channel and two Twitter accounts CMS Media Center: 37 References Part A and Part B Resources are located on the Cahaba GBA Home Page: where you can find: Appeals Process Cahaba GBA Listserv Comprehensive Error Rate Testing (CERT) New Evaluation and Management Information Center New Cahaba University New Resource Center for Providers (new and established) What s New Many more resources, including direct links to CMS resources Provider Contact Centers: Alabama, Georgia and Tennessee Providers: Mississippi Providers

20 Questions 39 Thank You for Signing Your Medical Records 40 20

21 Please complete lt your evaluations and post-test assessments. FAX to (205)