Otolaryngology Coding Alert

You are safe if you always remember to sign all orders or requisitions.

Are you confused about signature requirements for CT scans and allergy testing? You may already know that the Centers of Medicare and Medicaid Services (CMS) has tightened documentation and signature requirements by issuing Transmittal 327 Change Request 6698 in March 2010. However, you have to read between the lines.

Change Request 6698:What Is The Fuss All About?

CMS' Change Request 6698 (www.cms.gov/Transmittals/downloads/R327PI.pdf) revision came about with the aim of outlining the signature guidelines for medical review by Medicare claims review contractors -- now contained in the CMS Program Integrity Manual (Internet Only Manual Publication 100-08, Chapter 3, section 3.3.2.4; pages 1- 38; www.cms.gov/manuals/downloads/pim83c03.pdf).

The previous instruction required a "legible identifier" in the form of a handwritten or electronic signature for every service provided or ordered. In this CR, CMS updates these requirements and adds e-prescribing language.

The instruction was directed to Medicare administrative contractors (MACs), comprehensive error rate testing (CERT) contractors, and zone program integrity contractors (ZPIC). According to the policy, Medicare requires that services provided/ordered be authenticated by the billing physician for medical review purposes. The method used must be a hand written or an electronic signature, and Medicare will not accept stamp signatures.

Application: "This transmittal and resultant changes to the Program Integrity Manual is of particular importance to otolaryngology practices that orders and performs any diagnostic tests, such as CT scans, allergy testing, or audiology testing ordered and performed by the physician," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Where There Is A Rule, There Are Exceptions

These new regulations may be in place, but you can still override it based on the following exceptions:

• Exception 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

• Exception 2: There are some circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and the Medicare Benefit Policy Manual, chapter 15, section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.

• Exception 3: Other regulations and CMS instructions regarding signatures (such as timeliness standards for particular benefits) take precedence. 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 shall follow the guidelines listed below to discern the identity and credentials (e.g. MD, RN) of the signature. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.

"The second exception could be applicable to diagnostic testing outlined as intended in the plan of care in the progress note -- for example, the plan for a CT scan based on the history and exam with a patient with chronic nasal obstruction, looking for confirmation of chronic or acute sinusitis," explains Cobuzzi. You may also outline allergy testing in the plan of care within the progress note similarly to the one described in the second exception. "But under the second exception, even with the intent illustrated in the progress note, there must be authentication by the author via handwritten or electronic signature," she adds.

Drawing the line: The CMS Program Integrity Manual specifically describes that a handwritten signature as a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation. If the signature is illegible, the reviewer should consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry. Additionally, if a signature is missing an order, the contractor should disregard the order during review of the claim.

Bear In Mind The Timeliness Of Signatures

Remember, the billing physician should not add late signatures to the medical record -- beyond the short delay that occurs during the transcription process. Instead, he could make use of the signature authentication process.

As a correction mechanism for missing signature on the medical report, CMS created the signature attestation statement procedure. You may use this to incorporate reports that were not signed, for instance, and include it with documents requested for an audit. (You may refer to www.cms.gov/manuals/downloads/pim83c03.pdf for the complete attestation statement wording.)

The instructions for signature attestation statement mechanism include:

• An attestation statement must be signed and dated by the author of the medical record entry.
• An attestation statement must contain sufficient information to identify the beneficiary.
• An attestation statement must have documentation that is associated with the medical record entries and the author of record in question.
• In cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements.
• Reviewers will consider all attestations that meet the guidelines regardless of the date the attestation was created, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date.

Important: If the practice forgets to include the signature attestation with the audit documents, the auditor should contact the practice/biller and tell them about the missing signature. The auditor should also provide the practice/biller with the option to submit a signature log or a signature attestation within 20 days. "So, the auditor (MAC, CERT, ZPIC) actually should not be denying services for missing signatures. They should be notifying the practice/biller about the missing signature and asking them if they want to submit an attestation. The 20 day period starts from the date of the phone call requesting the attestation from the MAC, CERT or ZPIC," notes Cobuzzi.