MDS Alert

Physician and NPP order signature rules are being enforced by MACs, resulting in Medicare claim denials.

If you've noticed an uptick in denials for Medicare claims, you're not alone. Luckily, there may be a simple fix to prevent future denials.

The Medicare Manual rule requiring physicians who order therapy or other patient services to personally sign those orders is not new, but facilities are starting to see denials citing such technicalities. Medicare Administrative Contractors (MACs) are enforcing the rule when denying Medicare payment for orders in instances where the authoring physician did not sign the order.

Such a situation can arise pretty easily, especially if physicians and colleagues are verbally discussing therapy or other care options with a patient and forget to cross the t's and dot the i's.

If, for example, a nurse practitioner signs a therapy order that a physician gave verbally, the MAC may deny Medicare payment for that therapy because the authoring physician did not sign the order.

"This is one of the top reasons for Medicare denials," says Carol Maher, Rn-BC, RaC-Ct, RaC-Mt, CPC, director of education at Hansen Hunter & Co. P.C. in Vancouver, Washington.

The good news: You can prevent future denials of the same vein by adjusting your order processing and documentation across the board.

The bad news: Attestations are not allowed for physician's orders, making this particular denial very difficult to appeal, Maher says.

Take note of the specific information the Medicare Program integrity Manual (Revision 713) tells MACs in 3.3.2.4 - Signature Requirements: "Reviewers shall NOT consider attestation statements from someone other than the author of the medical record entry in question (even in cases where two individuals are in the same group, one should not sign for the other in medical record entries or attestation statements)."

Take note: "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author," the Medicare Program Integrity Manual says. "The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable."

Take a look at all of your systems for procuring orders, and make sure they are conducive to accurate, legible, and timely documentation - including the necessary signatures.

Your first (and most important) step should be educating physicians and nonphysician practitioners (NPP) about this rule and how its recent enforcement produces Medicare denials.

Look, too, toward the manner in which you record orders.

"I find that electronic orders are also problematic," Maher says. "Be sure that your nurses are carefully entering the name of the physician/NPP who is giving them a verbal or telephone order, because only the practitioner who gave the order can sign for that order.

"I find that sometimes facilities do not list all the NPPs or covering physicians in their electronic systems," she says. "When the actual person signs the printed order, it has the primary physician's name listed as the author of the order. That makes the order invalid."

The bottom line: Whoever authors an order should sign the order, Maher says.