When is a signature, not a signature? Did you know that Medicare has signature requirements? Judging from the number of emails that I have received from the MACs over the past few weeks, it would appear that Medicare’s long standing signature requirement is not being observed. A number of years ago, prompted in large part by the lack of signature compliance noted in the Comprehensive Error Rate Testing (CERT) audits, CMS released a MedLearn Matters article specifying Medicare signature requirements, noting that non-compliance is a reason for a contractor not to review a claim.
Medicare Signature Requirements – CERT Background
CERT randomly selects a statistically-valid, stratified random sample of Medicare FFs claims and reviews those claims and related medical records for compliance with Medicare coverage, payment, coding and billing rules. To accurately measure the performance of the Medicare claims processing contractors and to gain insight into the causes of errors, CMS calculates a national Medicare FFs paid claims improper payment rate and improper payment rates by claim type.
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.
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, §18.104.22.168. 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)
- Legible full signature
- Legible first initial and last name
- Illegible signature over a typed or printed name
- Illegible signature where the letterhead, addressograph or other information on the pages indicates the identify of the signatory.
- 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
- Initials over a typed or printed name
- Initials not over a typed/printed name but accompanied by a signature log or attestation statement
- 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:
- Illegible signature not over a typed/printed name not on letterhead and the documentation is unaccompanied by a signature log or attestation statement
- Initials not over a typed/printed name unaccompanied by a signature log, or attestation statement
- Unsigned typed note with provider’s typed name
- Unsigned typed note without providers typed/printed name
- Unsigned handwritten note, the only entry on the page
- “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, 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).
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. Coming up: electronic signature documentation.
Do you know Medicare signature requirements for outpatient therapy? Does your monitoring and auditing program ensure that signature requirements on the POC are met? Does your auditing and monitoring program ensure that therapy signature requirements are met for all therapy documentation.