Ophthalmology and Optometry Coding Alert

Question: We submitted our records to our MAC following a payer request, and for one physician in particular, he had everything documented and coded properly but we are being asked to refund money because he forgot to sign some of the documentation. Is this allowed?

Codify Subscriber

Answer: Yes, a missing signature is definitely cause for claim denials. “Signature issues are among the biggest findings in the comprehensive error rate testing (CERT) and medical error rate programs, said NGS Medicare’s Gail O’Leary during the MAC’s Sept. 19 webinar “Medicare Signature Guidelines.”

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, O’Leary said. “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, she noted. “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,” O’Leary added.

Therefore, you should include checking for signatures as part of your standard internal claims audits in your practice as a way to ensure that your practitioners are compliant with this requirement.