Anesthesia Coding Alert

Your anesthesia providers probably see Medicare patients frequently, maybe even on a daily or weekly basis. Therefore, mastering the skill of avoiding claim denials due to signature errors is crucial.

If you’ve ever puzzled over Medicare’s signature guidelines, fret no more. We’ve put together this handy guide to help clear up some of the confusion. Read on to learn the tips and tricks of acceptable Medicare signatures.

Tip 1: See That Signatures Meet Medicare Guidelines

The Centers for Medicare & Medicaid Services (CMS) requires that all services provided or ordered be authenticated by the author of the medical record. The appropriate method used for authenticating is either a handwritten or electronic signature.

Here are some examples of medical records requiring a signature:

• Dictated reports
• Lab/diagnostic orders/requisitions
• Certificates of medical necessity
• Treatment plans/plan of care
• Initial evaluations or current reevaluations
• Outpatient and inpatient visits

Handwritten signature defined: Medicare defines a handwritten signature as “a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.”

Don’t miss: You should only use a stamped signature as a very special exception. CMS permits use of a rubber stamp for a signature in accordance with the Rehabilitation Act of 1973, according to Gail O’Leary, provider outreach and education consultant with Medicare carrier National Government Services (NGS).

“Stamped signatures are only permitted in the case of an author with a physical disability who can provide proof of an inability to sign due to a disability,” explains Lori Langevin, NGS provider outreach and education consultant with the Part B Medicare Administrative Contractor (MAC). By affixing the rubber stamp signature, the provider certifies that they have reviewed the document.

Tip 2: Heed These Strict Rules for Electronic Signatures

Electronic signatures are valid — with some stipulations, indicates CMS.

First, it’s critical to understand that you can’t just generate a signature with your electronic health record (EHR). Your practice’s software and computer systems must have protections against e-signature modifications; moreover, these standards should be stringent enough to correspond with any current signature laws on the books.

Plus, “the individual [whose] name [is] on the alternate signature method and the provider accept responsibility for the authenticity of attested information,” reminds the Medicare Learning Network (MLN) fact sheet “Complying with Medicare’s Signature Requirements,” which can be accessed at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/cms1246723.

Additionally, Part B medications — “other than controlled substances” — should be ordered through an e-prescribing system, CMS guidance says.

For examples of acceptable e-signatures, check out this article published by MAC Palmetto GBA on its website at www.palmettogba.com/palmetto/jmb.nsf/DIDC/8EEM4Q2610.

Note: CMS encourages providers to check with attorneys and malpractice insurers to be sure their electronic signatures meet all the standards and regulations insurers have put forth.

Tip 3: Take Certain Steps If Signature Isn’t Legible

In some cases, your provider’s signature may be illegible. If this happens, you can submit a signature log or an attestation statement with the claim to support the identity of the individual who provided the illegible signature.

If you are gathering medical documentation, and you notice the signature is illegible, go ahead and include an attestation statement or signature log to affirm the signature is the provider’s, O’Leary says. Doing this will help avoid delays in the review process.

Signature log: A signature log is a typed listing of the provider(s) identifying their name with a corresponding handwritten signature. You must also include the credentials associated with the initials or the illegible signature, O’Leary explains. There can be an individual log consisting of one person or a group log consisting of all the doctors in the entire practice.

Don’t miss: You may include the signature log on the same page where the initials or illegible signature is located or in a separate document, O’Leary says. Just make sure that the signature log is a part of the patient’s medical record.

A signature log can be created at any time,” Langevin adds. “MACs will accept all submitted signature logs, regardless of the date they were created.

If you are not able to get a signature list from your anesthesia group, make your own — cut and paste the anesthesia providers’ signatures and/or initials on a list with their typed names — and send it to them for approval. This makes it possible for someone outside of the group to recognize information easily.

Attestation statement: You can also submit an attestation statement if the provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, according to O’Leary. The statement must also include the appropriate patient information.

Tip 4: Handle Amendments and Corrections Like This

If you ever have a case where you must deal with amendments, corrections, or delayed entries in the medical documentation, you must make sure that your practice heeds certain recordkeeping principles, says Langevin. Any document you submit to your MAC should “clearly and permanently identify any amendment, correction, or delayed entry as such,” she notes.

You also want to make sure that you mark the date and the author of any amendment, correction, or delayed entry, as well as the original date of the entry you are correcting.

And you should identify the original content of the record, without deletion. This is very important, Langevin says. You should never delete anything from a medical record.

Paper medical records: In the case of a paper medical record, you can perform a correction by using a single line to strike through the content. Make sure the original content is still legible. And the person who makes the alteration to the record should sign and date it.

Electronic health records: For EHRs, the original content, modified content, and date and authorship of each modification in the record must also be clearly identified.