Ophthalmology and Optometry Coding Alert

Once you’ve tightened up your medical documentation, there’s one last piece of the equation that you can’t forget — the provider’s signature.

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. Stamped signatures are not acceptable with the exception of the author having a physical disability that prevents them from signing the record.

Unsigned documentation or a lack of attestation will result in a claim denial. Medicare’s definition of a handwritten signature is a mark or sign by an individual on a document to signify their knowledge, approval, acceptance or obligation.

To ensure that you successfully meet CMS’ signature guidelines and avoid denials, follow these five steps.

Step 1: Know When the Signature Itself Needs Support

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 provider in question, which can include a signature log and/or an attestation.

Providers can sometimes include a signature log in the documentation they submit that lists the type or printed name of the author along with credentials associated with initials for an illegible signature. A signature log is a typed listing of the providers identifying their names with corresponding handwritten signatures. 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 documentation.

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.

Step 2: 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.

The documentation must support evidence that the supervisor was present and available. The documentation submitted to support billing incident to services must clearly link the services of the NPP auxiliary staff to the services of the supervising physician. You want to make sure the name and the professional destination of the person rendering the service is legible in the documentation for the service.

Step 3: Consider the Exceptions

As with most rules, some exceptions do apply to the signature regulations. The first exception is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

In addition, orders for clinical diagnostic tests need not be signed, but the treating physician must have medical documentation indicating that he or she intended the clinical diagnostic test to be performed, and that documentation must be authenticated by the author via a handwritten or electronic signature.

The third exception involves other regulations and CMS instructions regarding signatures – these can take precedence sometimes over the standard regulations. For medical review purposes, if the relevant regulation, NCD, LCD, and CMS manuals are silent on whether the signature is legible or present and the signature is illegible/missing, the reviewer will follow guidelines to discern the identity and credentials of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.

The final exception indicates that CMS permits use of a rubber stamp for signatures in accordance with the Rehabilitation Act of 1973, which states that an author with physical disability has to provide proof of their inability to sign due to their disability. In those cases, a rubber stamp would be permitted.

Step 4: Find out Which E-Signatures Work

If you’re wondering which types of e-signatures are acceptable from a Medicare standpoint, consider these 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
• “Authorized by: 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

Step 5: Get 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.

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.