Medicare Compliance & Reimbursement

Home health agencies are asking for denied claims if they aren't up on the latest physician signature guidance from the feds, but that news is changing fast.

Hospices cheered the Centers for Medicare & Medicaid Services' (CMS) Jan. 15 announcement that it would issue a "clarification" of Change Request 5550 (Transmittal 220) -- the transmittal that has caused considerable confusion among home health agencies and hospices.

The clarification will include the news that electronic signatures are acceptable for hospice certifications of terminal illness (CTIs), CMS told the National Association for Home Care & Hospice on Jan. 15.

CMS quietly fine-tuned its requirements for signatures on orders and "other medical record documentation for medical review purposes" last summer in CR 5550.

CMS sent that Aug. 24 missive only to the regional home health intermediaries (RHHIs) and gave it an almost immediate effective date of Sept. 3, 2007.

The hoopla over the transmittal started late last year when Medicare contractor Palmetto GBA posted provider education on the change, noting that CMS' new language "eliminates the ability to use physician stamped signatures and has a special exception for hospices requiring that the 'Signature(s) of the physician(s) must be written on the certifications of terminal illness for hospice.'"

On Jan. 1, Medicare contractor Cahaba GBA notified hospices that it would deny claims "if the physician's signature dated Sept. 3, 2007, or later, is not hand written on the certification of terminal illness."

Adding to the confusion, a CMS official noted at the Jan. 9 home health Open Door Forum that CR 5550 did indeed drop the word "stamped" from a section outlining signature requirements for all provider types, including not only hospices but also home health agencies. An official also said during the forum that faxed CTIs signed by physicians were unacceptable by CR 5550 standards.

After the Jan. 9 Open Door Forum, CMS downplayed any shift to its signature policy, even denying that the policy had changed.

"We have not changed the signature requirements," a CMS official said before announcing that the agency would reissue CR 5550 with clarifications.

At the forum, "CMS was asked whether we would accept electronic signatures on the hospice certification, and we said we would have to look into it," she added. "We do not have anything further to say at this point."

The reissue of CR 5550 "will take place as soon as possible," NAHC assured its members in a Jan. 15 bulletin, adding that the effective date for the clarified CR 5550 will be 90 days from the date the new version is issued.

In the meantime, keep in mind that stamped signatures are no longer permitted.

"The transmittal drops the phrase 'stamped signatures' as a permissible method of physician verification on medical records," notes Heather Vasek, director of public policy for the Texas Association for Home Care.

At the home health Open Door Forum, CMS' Pat Sevast confirmed that home health orders should not be substantiated with stamped signatures.

"Home care agencies need to be made aware that the changed signature requirements are applicable to them and not just hospice," Kim Skehan of the Connecticut Association for Home Care says.

In addition, remember that signatures on hospice CTIs must be "written" -- but CMS has clarified that electronic and faxed submissions are both acceptable. Hospices do not have to obtain the original when they receive such a faxed certification, confirms NAHC's Janet Neigh.

To read the original CR and watch for the reissue of the guidance, go to http://www.cms.hhs.gov/transmittals/. The new signature requirements are described in Section 3.4.1.1.