EM Coding Alert

These 5 simple steps will help you avoid claims denials, compliance issues.

Making sure the right person signs medical documentation in the right way may seem like a trivial component of your job. Yet “signature issues are among the biggest findings in the comprehensive error rate testing (CERT) and medical error rate programs,” said NGS Medicare’s Gail O’Leary during the MAC’s Sept. 19 webinar “Medicare Signature Guidelines.”

So, with denials and compliance problems on the line, you might want to refresh your knowledge of Medicare’s definitions regarding what constitutes an acceptable signature and take these five steps to satisfy Medicare requirements.

Step 1: Know When the Signature Itself Needs Support

First, some guidelines. Medicare requires that services provided or ordered be authenticated by the author, and the method used for authenticating must be a handwritten or electronic signature, O’Leary said. “Medicare’s definition of a handwritten signature is a mark or sign by an individual on a document to signify their knowledge, approval, acceptance, or obligation,” O’Leary noted. Unsigned documentation, or a lack of attestation, will result in a claim denial according to O’Leary.

In some cases, the provider will sign a document, but the signature isn’t necessarily one that would appear legible to the average reviewer. In these cases, you have the option of creating, maintaining, and submitting additional documentation to demonstrate that the signature actually belongs to the provider in question, which can include a signature log and/or an attestation.

“Providers can sometimes include a signature log in the documentation they submit that lists the type or printed name of the author along with credentials associated with initials for an illegible signature,” O’Leary said. “A signature log is a typed listing of the providers identifying their names with corresponding handwritten signatures. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation.”

Providers might also include an attestation statement. To be considered valid by Medicare, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

At any given time, you can submit an attestation statement, signature log, or a document affirming that the signature belongs to the provider if you find the signature to be illegible. “The signature documents can be submitted routinely for all requests for medical records, so in other words, don’t wait for us to ask for it – by all means, send it in,” O’Leary said.

Step 2: Determine Who Must Sign

In most cases, the provider who performed or ordered the service will sign the record, but there are situations when coders have questions about who needs to sign. For instance, it can be confusing to know which provider should enter a signature on the documentation for an incident-to service, but the reality is that the record should be signed by the person who performs the service, not the supervising physician.

“The documentation must support evidence that the supervisor was present and available,” O’Leary said. “The documentation submitted to support billing incident-to services must clearly link the services of the NPP auxiliary staff to the services of the supervising physician. You want to make sure the name and the professional designation of the person rendering the service is legible in the documentation for the service.”

Step 3: Consider the Exceptions

As with most rules, some exceptions do apply to the signature regulations, said NGS Medicare’s Lori Langevin during the webinar.

The main exception for E/M documentation involves other regulations and CMS instructions regarding signatures – these can take precedence sometimes over the standard regulations. “For medical review purposes, if the relevant regulation, NCD, LCD, and CMS manuals are silent on whether the signature is legible or present and the signature is illegible/missing, the reviewer will follow guidelines to discern the identity and credentials of the signer,” Langevin said. “In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.”

The final exception indicates that CMS permits use of a rubber stamp for signatures in accordance with the Rehabilitation Act of 1973, which states that an author with physical disability has to provide proof of their inability to sign due to their disability. In those cases, a rubber stamp would be permitted.

Step 4: Find out Which E-Signatures Work

If you’re wondering which types of e-signatures are acceptable from a Medicare standpoint, Langevin answered that by offering a few examples, as follows:

• “Reviewed by” with provider’s name
• “Released by” with provider’s name
• Chart “Accepted by” with provider’s name
• “Electronically signed by” with provider’s name
• “Verified by” with provider’s name
• “Signed before import by” with provider’s name
• Digitalized signature: Handwritten and scanned into the computer
• “Authorized by: John Smith, MD”
• “Digital Signature: John Smith, MD”
• “This is an electronically verified report by John Smith, MD”
• “Authenticated by John Smith, MD”
• “Confirmed by” with provider’s name
• “Electronically approved by” with provider’s name
• “Closed by” with provider’s name
• “Finalized by” with provider’s name

Step 5: Get the Rules on Amendments

Medicare requires you to document services in the medical record at the time of rendering, but in some instances, that isn’t always possible. If you realize after the fact that the documentation needs to be corrected, amended, or completed, you must ensure that your amendment is in line with Medicare’s amendment regulations.

Documents submitted to MACs containing amendments, corrections, or addenda must meet the following requirements, Langevin said:

1. Clearly and permanently identify any amendment, correction, or delayed entry as such

2. Clearly indicate the date and author of any amendment, correction, or delayed entry, and original date of entry being corrected

3. Clearly identify all original content, without deletion.

“We’re not going to consider undated or unsigned entries handwritten in the margin of a document,” she said.

In addition, if there is a correction to make, it should never be erased; a neat cross out can be added if the date and initials of the person making the change is clear, but added information should make clear there was inaccurate information being corrected and indicate what the new information is.