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Updated Signature Guidelines for Medical Review Purposes

Medicare requires that services provided/ordered must be authenticated by the author with either a hand written or electronic signature (stamps are not acceptable), although there are a few exceptions: (1) facsimiles of original written/electronic signatures are acceptable for the certification of terminal illness for hospice; (2) some orders do not need to be signed, for example, clinical diagnostic tests are not required to be signed; (3) in cases where other regulations and CMS instructions have signature requirements, those requirements take precedence.

On March 16, 2010, CMS published CR 6698, which updates signature requirements and adds E-Prescribing language. As of April 16, 2010, the signature requirements are applicable for reviews; however, the requirements are effective retroactively for Comprehensive Error Rate Testing (CERT) for the November 2010 report period.

According to CR 6698, AC, MAC, and CERT reviewers shall proceed to signature assessment only if the criteria in the relevant Medicare policy cannot be met but for a key piece of medical documentation which contains a missing/illegible signature. ACs, MACs, RACs, PSCs, ZPICs, and CERT contractors shall give deference to other regulations and CMS instructions regarding signatures, and if the relevant regulation is silent on whether the signature must be dated, the reviewer shall ensure that the documentation contains enough information to determine the date on which the service was ordered.

Keep in mind that a handwritten signature is a mark/sign by an individual on a document to signify knowledge, approval, acceptance, or obligation. If the signature is illegible, ACs, MACs, PSCs, ZPICs, and CERT shall consider evidence in a signature log or attestation statement. If the signature is missing, the order shall be disregarded. If the signature is missing from any other medical documentation, a signature attestation from the author of the medical record entry shall be accepted.

At this time, AC, MAC, CERT, PSC, and ZPIC reviewers shall NOT accept as a valid order any controlled substance drugs that are ordered through any E-Prescribing system (reviewers shall only accept hardcopy pen and ink signatures in that case). However, reviewers will accept as a valid order any Part B drugs, other than controlled substances, ordered through a qualified E-Prescribing system. Also, AC, MAC, CERT, PSC, and ZPIC reviewers shall accept as a valid order any drugs incident to DME, other than controlled substances, ordered through a qualified E-Prescribing system.

For more information on the revised Medicare regulations, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510, or visit the HLP website.

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