Home Health & Hospice Week

Break down CMS’s requirements before you take a chance on the wrong use of signatures.

Are you confused about signature requirements for Medicare? You may already know that CMS tightened documentation and signature re-quirements by issuing Transmittal 327, Change Request 6698 in March 2010, which was subsequently revised last November. However, you have to read between the lines to know exactly how a signature should be documented.

Know the Signature Rules

The Centers for Medicare & Medicaid Services’ Change Request 6698 revision came about with the aim of outlining the signature guidelines for medical review by Medicare claims review contractors. The previous instruction required a "legible identifier" in the form of a handwritten or electronic signature for every service provided or ordered. Thanks to the change, however, CMS updated these requirements and added e-prescribing language.

According to the policy, Medicare requires a hand written or an electronic signature, and Medi-care will not accept stamp signatures, except in very rare situations (see related box, p.156).

Know This Hospice Exception To Signature Rules

These signature regulations may be in place, but you can still override them based on the following exceptions:

Exception 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

Exception 2: Other regulations and CMS instructions regarding signatures (such as timeliness standards for particular benefits) take precedence. 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 shall follow the guidelines to discern the identity and credentials (e.g. MD, RN) of the signature. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.

Drawing the line: The CMS Program In-tegrity Manual specifically requires that a handwritten signature as a mark or sign by an individual on a document is present to signify knowledge, approval, acceptance or obligation. If the signature is illegible, the reviewer should consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.

Bear In Mind The Timeliness Of Signatures

Remember, clinicians should not add late signatures to the medical record. Instead, they could make use of the signature authentication process if necessary.

As a correction mechanism for missing signatures, CMS created the signature attestation statement procedure. You may use this to incorporate reports that were not signed, for instance, and include it with documents requested for an audit.

The instructions for signature attestation statement mechanism include:

• An attestation statement must be signed and dated by the author of the medical record entry.
• 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.

Important: If someone other than the author of the medical record entry in question signs the attestation statement, Medicare claims reviewers cannot accept them. "Even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements," CMS says in the transmittal.