Podiatry Coding & Billing Alert

Documentation:

Keep Your Documentation Claims Clearly Legible and Free from Denials

Focus on CMS signature requirements or you risk the wrong use of signatures.

If you’re edgy about CMS’s 2016 CBR detailing physician documentation errors (you know, the one that targets podiatrists), then you’re not alone.

Don’t expose your podiatry practice to unnecessary risks for audits and denials by making careless signature errors. Pay attention to these tips and you’ll stay on top of your CMS documentation guidelines and audit-free.

Focus on Signature Legibility

According to the policy (Medicare Program Integrity Manual 3.3.2.4), Medicare requires that services provided/ordered be authenticated by the billing physician for medical review purposes. The method used must be a legible handwritten or an electronic signature with the provider’s credentials, and Medicare will not accept stamp signatures.

However, you may use a stamp to provide a legible interpretation of the provider’s signature, which is still required.

Every entry in a patient’s medical record must be legible to another reader to a degree that a meaningful review may be conducted. If the signature is not legible and does not identify the author, a printed version should also be recorded. The policy is of particular importance to practices that order and perform any diagnostic tests, such as CT scans or imaging studies.

Know the Authentication Rules

Authentication must be either a handwritten or an electronic signature. Note that signature stamps are not acceptable for Medicare and many other payers. In the office setting, initials are acceptable as long as they clearly identify the author. Every medical record must have authentication.

Every service your medical staff provides or orders should be authenticated by the author, says Marsha S. Diamond, CPC, CPC-H, CCS, coding textbook author in the Audioeducator.com audioconference “Compliance: It’s Not Just About Coding.” All notes should be dated, preferably timed, and signed by the author.

Handwritten signature will be considered a “mark or sign.” If the signature is illegible, Medicare shall consider evidence in a signature log. Lack of such supporting documentation will result in claims denial.

Every note must stand alone, meaning that the performed services must be documented at the onset. The medical record must stand on its own with the original entry corroborating that the service was rendered and medically necessary.

And Don’t Forget Your Scribe Rules

If a nurse or non-physician practitioner (NPP), such as a physician assistant or nurse practitioner, acts as a “scribe” for the provider, the individual writing the note or entry in the record should reflect this in the notes.

For example, Noridian guidelines state:

  • Record entry lists the name of the person “acting as a scribe for Dr. X.”
  • Example: “I, ___________, am scribing for, and in the presence of, Dr. ______

The physician should then co-sign and date the record, and also indicate that the note accurately reflects work and decisions he made during the encounter.

According to Diamond, it would be inappropriate for an employee of the physician to make rounds or see patients at one time and make entries in the record and then the provider make rounds later and note ‘agree with above,’ unless the employee is a licensed, certified provider (NP/PA) billing for services under his/her own name/number.

Signature Timeliness Matters

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 if necessary.

When your providers actually complete their documentation matters. “Documentation should be generated at the time of service or, as Medicare puts it, ‘shortly thereafter,’” Diamond explains.

Delayed entries within a “reasonable” period of time are acceptable for the purposes of:

  • Clarification
  • Error correction
  • Addition of information initially not available
  • Unusual circumstances prevented generation of note at time of service (for example, if your EMR system is not working).

Payers don’t typically give a set timeframe on what qualifies as “shortly thereafter.” Diamond explains that the rule is usually that you are in good shape “as long as the documentation is in the chart and documented in the time that the author has ‘total recall’ of the patient encounter or service.”

Take note: 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.

If someone other than the author of the medical record entry in question signs the attestation statement, Medicare claims reviewers cannot accept them. “Even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements,” CMS says.

For more information on these guidelines, check the link at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.