General Surgery Coding Alert

Don’t lose pay over this easy compliance fix.

Even a coder who’s mastered CPT^® and ICD-10-CM can’t “save the claim” if providers fail to adequately sign the medical records.

“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 recent webinar “Medicare Signature Guidelines.”

Here’s why: Medicare requires that services provided or ordered be authenticated by the author, and the method used for authenticating would be a handwritten or electronic signature, O’Leary said. Unsigned documentation or a lack of attestation will result in a claim denial, she noted.

To ensure that you successfully meet CMS’ signature guidelines and avoid denials, follow these five steps.

Step 1: Know When the Signature Itself Needs Support

Sometimes your surgeon might sign a document with an illegible signature, and that’s when you can use a signature log or attestation to demonstrate that the signature belongs to the provider in question.

“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.

Step 2: Determine Who Must Sign

The author of the document should always be the person who signs the document. “This can be confusing in the electronic world, but consider that it would be odd, in a paper note, to see one provider sign another provider’s notes,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr. “The same rule applies in the electronic medical record (EMR). When in doubt, consider whether it makes sense for a paper record.”

That holds even in cases of an incident-to service. The person who performs the service and writes the note should sign, not the supervising physician. “However, the documentation must support evidence that the supervisor was present and available,” O’Leary said.

Step 3: Consider the Exceptions

As with most rules, some exceptions apply to the signature regulations, said NGS Medicare’s Lori Langevin during the webinar. The first exception, she said, is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

In addition, orders for clinical diagnostic tests need not be signed, but the treating physician must have medical documentation indicating that he or she intended the clinical diagnostic test to be performed, and that documentation must be authenticated by the author via a handwritten or electronic signature.

The third exception involves other regulations and CMS instructions regarding signatures – these can have priority over the standard regulations. “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 must 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
• “Authorized by: John Smith, MD”
• “Digital Signature: John Smith, MD”
• Digitalized signature: Handwritten and scanned into the computer
• “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.