Medicare Compliance & Reimbursement

Tip: Remember CMS does not permit attestations on physician's orders.

If you've noticed an increase in documentation scrutiny for Medicare claims, you're not alone.

Physician and NPP order signature rules are being enforced by MACs more often, resulting in higher claim denials. Review the requirements with your team to ensure your Medicare pay is intact in 2018.

Background: CMS requires physicians who order therapy, lab tests, or other patient services to personally sign orders, but practices are starting to see an uptick in denials related to such technicalities. And as Medicare Administrative Contractors (MACs) continue to earmark documentation faux pas in their Targeted Probe and Educate (TPE) reviews, it's essential for practices to work together to eradicate instances where the authoring physician did not sign the order.

Such situations can arise pretty easily, especially when colleagues verbally discuss 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)."

Reminder: "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."

Note These 3 Necessities to Ensure the Signature is Acceptable

CMS clearly outlines what constitutes a "valid signature." According to the agency's guidance, you should consider these three questions before you send over your Medicare claims:

• Are the ordered and/or performed services properly authenticated by the ordering provider?
• Are the signatures handwritten or electronic in nature? (Note that stamped signatures are acceptable in cases where the Medicare provider has a documented disability that is known to the MAC and impedes a handwritten or electronic signature).
• Is the signature legible?

Heed This Expert Advice

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.

Office staff, both clinical and administrative, need to be aware of the ramifications of a missed signature. Starting with physicians and nonphysicians (NPPs) down the line, it's important that everyone understands the rules and how the MACs are enforcing the requirement.

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."

Scribes: A scribe with a thorough knowledge of medical terminology and a familiarity with everyday encounters, procedures, and commonly-used medications can be an office asset. But remember a scribe should not independently document anything other than the review of systems (ROS) and past medical, family, and social history (PFSH), according to CMS guidance.

Scribes do not have to sign the documentation, but its recommended that they are identified in the medical record, suggests MAC Novitas Solutions in its online "Scribe Services" advice. The scribed documentation, however, does need to show who performed the service as well as be "signed and dated by the treating physician or NPP affirming the note adequately documents the care provided," Novitas reminds.

Best advice: Whoever authors an order should sign the order, Maher says.

Resource: To review the Medicare Program Integrity Manual, Chapter 3, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.