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Medicare Signature Requirements – Update

August 26, 2015 1 Comment

Medicare recently updated signature requirements in Transmittal 604 to the Medicare Medicare Signature RequirementsProgram Integrity Manual.    The updates include the inclusion of the Supplemental Medical Review Contractor (SMRC) to the list of contractors (MACs, ZPICs, CERT) bound by the policy that we reviewed in a previous post. Many providers may remember that the current SMRC is Strategic Health Solutions which published several audit reports on therapy in 2013.  The second update includes a stipulation that:

If the signature is illegible, MACs, ZPICs, SMRC, and CERT shall consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry.

Medicare Signature Requirements – Plan of Care

For therapy providers signatures are important where a physician signature is on a therapy order and/or certification of the plan of care, as well as all the provider required signature on documentation including the plan of care, daily treatment notes, progress reports and discharge reports.  In the Medicare Benefits Policy Manual( MBPM), Chapter 15, beginning at Section 220, certification is defined as “physician’s/nonphysician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.”  Note that the signature requirement also required a date, and this is for the purpose of assessing whether certification is timely or delayed.  Signature per CMS (also found in the above MPBM referenced section)  is a “legible identifier of any type acceptable according to policies in Pub. 100-08, Medicare Program Integrity Manual chapter 3, § concerning signatures.”  Most therapy providers don’t routinely reference the Medicare Program Integrity Manual, but the requirements are noted in the MedLearn Matters article.  This is a quick summary of when a signature of a physician to certify a therapy plan of care is met, contrasted to when it is not met:

Medicare signature requirements are met for the certification: (keep in mind certifications must be dated)

  1. Legible full signature
  2. Legible first initial and last name
  3. Illegible signature over a typed or printed name
  4. Illegible signature where the letterhead, addressograph or other information on the pages indicates the identify of the signatory.
  5. Illegible signature not over a typed/printed name and not on letterhead, but the submitted documentation is accompanied by a signature log or attestation statement
  6. Initials over a typed or printed name
  7. Initials not over a typed/printed name but accompanied by a signature log or attestation statement
  8. Unsigned handwritten note where other entries on the same page in the same handwriting are signed

Medicare signature requirements are NOT met for the certification:

  1. Illegible signature not over a typed/printed name not on letterhead and the documentation is unaccompanied by a signature log or attestation statement
  2. Initials not over a typed/printed name unaccompanied by a signature log, or attestation statement
  3. Unsigned typed note with provider’s typed name
  4. Unsigned typed note without providers typed/printed name
  5. Unsigned handwritten note, the only entry on the page
  6. “Signature on File”

If you have charts wherein the signature requirements are not met, CMS provides guidance on the use of signature attestation or signature log or other document:

If the signature is illegible, MACs, ZPICs, SMRC, and CERT shall consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry.

, and providers an example of an attestation statement.  Just in case you were wondering CMS does not allow stamped signatures (there are a few very rare exceptions – included a disable physician).

Medicare Signature Requirements – The OIG and Therapy

When reviewing a claim if there are reasons for denial not related to signature requirements, the review contractor need not proceed to signature authentication.   However, if the missing element in the documentation is a missing or illegible signature, the review must, per Medicare policy must proceed to a signature assessment. In recent cases under the OIG Work Plan to review physical therapists in private practice the OIG has cited the provider under review for failure to meet signature requirement.  Of note, in the most recent case published, the signature requirements were met through attestation, (per the provider’s response to the OIG Draft Report), however the OIG did not concur with the provider’s statutory analysis and basis for providing the attestations.  The moral of the story may very well be that even though there is a basis for curing a deficit in a signature, it may not be accepted during an audit, and the provider may be forced into an appeal.

CMS has also released a brochure on signature requirements in addition to the MedLearn Matters article mentioned above.  The CMS materials provide more context to various situations, many not applicable to outpatient therapy.  As CMS always states “it is the supplier’s responsibility to know Medicare rules”.  This post has highlighted signature requirements for the therapy plan of care.  Feel free to jump ahead and read both the CMS MedLearn Matters article as well as the CMS brochure on signature requirements.  Stay tuned to future posts on therapy signature requirement in documentation as well as electronic documentation.

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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  1. Medicare Signature Requirements – Update | HealthBACON | August 27, 2015

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