Ophthalmology and Optometry Coding Alert

Hint: Don’t forget attestations when signatures are late.

You pride yourself on the meticulous detail in your medical record, right down to the diagnosis codes and the time spent with the patient. But if you forget to actually sign the record, you could be flushing money down the drain.

That was the word from eye care coder Ann Bina, who discussed the topic during Eye Care Leaders’ March 20 webinar, “CMS Billing Regulation Review.” Check out the following tips that can ensure you don’t sacrifice any pay due to signature snafus.

Signed Notes Are the Only Acceptable Notes

Without a signature or other authentication, payers won’t consider your medical documentation valid. “Regardless of who writes the medical record entry, the record must be authenticated by the provider,” Bina said.

Here’s why:  Medicare requires that services provided or ordered be authenticated by the author, and the method used for authenticating would be a handwritten or electronic signature. In some situations, stamped signatures are permitted, provided that the author has a physical disability that prevents them from signing the record.

Unsigned documentation or a lack of attestation will result in a claim denial, Bina said – and this could cost your practice thousands in forfeited reimbursement if you aren’t following the signature requirements.

In some cases, the provider will sign a document but the signature isn’t necessarily one that would appear legible to the average reviewer. In these cases, you have the option of creating, maintaining, and submitting additional documentation to demonstrate that the signature actually belongs to the physician in question.

Providers can sometimes include a signature log in the documentation they submit that lists the printed name of the author along with credentials associated with initials for an illegible signature, Medicare guidelines state.

“A signature log is a typed listing of physicians and NPPs identifying their names with a corresponding handwritten signature,” CMS says in its document, Complying With Medicare eSignature Requirements. “This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record. CMS encourages but does not require physicians and NPPs to list their credentials in the log.”

Providers might also include an attestation statement. To be considered valid by Medicare, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

You can typically submit an attestation statement, signature log, or a document affirming that the signature belongs to the provider if you find the signature to be illegible.

Determine Who Must Sign

In most cases, the provider who performed or ordered the service will sign the record, but there are situations when coders have questions about who needs to sign. For instance, for an incident-to service, it can be confusing to know which provider should enter a signature on the documentation, but the reality is that the record should be signed by the person who performs the service, not the supervising physician.

If you’re wondering which types of e-signatures are acceptable from a Medicare standpoint, consider the following acceptable examples:

• “Reviewed by” with provider’s name
• “Released by” with provider’s name
• Chart “Accepted by” with provider’s name
• “Electronically signed by” with provider’s name
• “Verified by” with provider’s name
• “Signed before import by” with provider’s name
• Digitalized signature: Handwritten and scanned into the computer
• “Authorizedby: John Smith, MD”
• “Digital Signature: John Smith, MD”
• “This is an electronically verified report by John Smith, MD”
• “Authenticated by John Smith, MD”
• “Confirmed by” with provider’s name
• “Electronically approved by” with provider’s name
• “Closed by” with provider’s name
• “Finalized by” with provider’s name

Know the Rules on Amendments

Medicare requires you to document services in the medical record at the time of rendering, but in some instances, that isn’t always possible. If you realize after the fact that the documentation needs to be corrected, amended, or completed, you must ensure that your amendment is in line with Medicare’s amendment regulations.

Late signatures shouldn’t be added to the medical record, Bina said. Anything beyond a short delay that happens during the transcription or medical record documentation period is considered “late.” If it’s late, an attestation is required. But whereas signature requirements come from national guidelines, attestations for late signatures tend to be carrier-specific. “Ask your MAC or carrier what their attestation/late signature guidelines are,” Bina advised.

Typically, documents submitted to MACs containing amendments, corrections, or addenda must meet the following requirements:

1. Clearly and permanently identify any amendment, correction, or delayed entry as such
2. Clearly indicate the date and author of any amendment, correction, or delayed entry, and original date of entry being corrected
3. Clearly identify all original content, without deletion.