Neurosurgery Coding Alert

Remember: You should only use a stamped signature as a very special exception.

Ensuring your medical documentation is complete and accurate is a crucial component of submitting your claims. And, if you don’t understand the many nuances of Medicare’s signature requirements, you could be setting your practice up for failure.

Take a look at this advice from a recent National Government Services’ (NGS) webinar regarding Medicare’s signature requirements to keep your claims in tip-top shape.

Make Certain Signatures Are Valid

When checking the validity of the signatures within your medical documentation, you must make sure they meet the following criteria, says Lori Langevin, NGS provider outreach and education consultant:

• The signature is handwritten, electronic, or stamped (a special exception).
• The signature is legible. (If the signature is illegible, you can submit a signature log or attestation statement).
• The ordering physician authenticated the services he provided or ordered.

Caution: You are allowed to use a stamped signature under very special circumstances.

CMS permits use of a rubber stamp for a signature in accordance with the Rehabilitation Act of 1973, says Gail O’Leary, NGS provider outreach and education consultant.

“Stamped signatures are only permitted in the case of an author with a physical disability who can provide proof of an inability to sign due to a disability,” Langevin adds.

Follow These Guidelines for Electronic Signatures

If your provider uses electronic signatures, make sure they meet the following certain requirements, Langevin says:

• The systems and software your office uses should be protected against modification.
• Your administrative safeguards must follow standards and laws.
• Teach your office that whoever’s name is on the alternate signature method and the provider are taking responsibility that the attested information in the medical record is true.
• Include a copy of your office’s electronic signature protocol procedure.

Signature Not Legible? Do This

If your physician’s signature is illegible, you can consider submitting a signature log or an attestation statement.

“A signature log is a typed listing of the provider or providers identifying their name with a corresponding handwritten signature,” O’Leary says. You must also include the credentials associated with the initials or the illegible signature.

Don’t miss: You may include the signature log on the same page where the initial or illegible signature is located or in a separate document, according to O’Leary. Just make sure that the signature log is a part of the patient’s medical record.

Attestation statement defined: You can also submit an attestation statement if the provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, O’Leary says. The statement must also include the appropriate patient information.

Keep Your Cool When Handling Corrections

If you must deal with amendments, corrections, or delayed entries in your medical documentation, make sure your practice follows specific recordkeeping principles, Langevin says. Any document you submit to your MAC should “clearly and permanently identify any amendment, correction, or delayed entry as such.”

You also want to make sure that you clearly mark the date and the author of any amendment, correction, or delayed entry, as well as the original date of the entry you are correcting.

And, you should clearly identify the original content of the record, without deletion. This is very important, Langevin says. You should never delete anything from a medical record.

Paper medical records: With paper medical records, you can perform a correction by using a single line to strike through the content. Make sure the original content is still legible, and the individual who makes the alteration to the record should sign and date it.

Electronic health records: For electronic health records (EHRs), make sure they distinctly identify the amendments, corrections, or delayed entry, according to Langevin. The original content, modified content, and date and authorship of each modification in the record must also be clearly identified.