CMS issues signature guidelines for medical review

For medical review purposes, provided/ordered Medicare services must "be authenticated by the author" via a handwritten or electronic signature (i.e., stamp signatures are not acceptable), says the Centers for Medicare and Medicaid Services (CMS) in Transmittal 327 (change request 6698), which updates Chapter 3 of the Medicare Program Integrity Manual. Prior to this update, CMS required "a legible identifier" rather than author authentication.

CMS has expanded the exceptions to the signature requirement. Previously, hospice providers enjoyed the only exception, with CMS stating that facsimiles of original written or electronic signatures are acceptable for hospice certifications. But "there are some circumstances for which an order does not need to be signed," the agency now notes. For example, orders for clinical diagnostic tests don't have to be signed. However, such unsigned test orders must be accompanied by "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." In addition, medical reviewers should give precedence to other regulations and CMS instructions (e.g., national coverage determinations, local coverage determinations, and on-line CMS manuals) regarding signatures.

CMS has provided guidelines on signature authentication for medical reviewers to follow when other precedential instructions are silent. The updates cover signature logs, signature attestation statements, illegible or missing handwritten signatures and electronic prescribing.

With signature logs that list the typed or printed name of the author associated with initials or an illegible signature, CMS reins in overzealous medical reviewers who are too quick to deny claims. For example, "reviewers may encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials," says the agency.

Attestation statements are invalid for medical review purposes unless "signed and dated by the author of the medical record entry and [containing] sufficient information to identify the beneficiary, says CMS. The agency includes a sample attestation statement that providers may choose to use and give strict instructions when attestation statements may not be considered.

CMS illustrates how medical reviewers should handle missing signatures, as well as giving detailed instruction on when an illegible signature meets--or does not meet--the signature requirement. For example, initials over a typed or printed name fulfill the signature requirement. However, initials Not over a typed or printed name that are also unaccompanied by either a signature log or an attestation statement don't fulfill the signature requirement. When signature requirement are unmet according to these guidelines, medical reviewers should contact providers and ask them if they want to submit an attestation statement or signature log within 20 calendar days.

With the exception of controlled substances, medical reviewers should "accept as a valid order" any Part B drugs or any drugs incident to DME (durable medical equipment) ordered through a qualified e-prescribing system, says CMS. However, they should "Not accept as a valid order any controlled substance drugs that are ordered through any e-prescribing system, even one which is qualified under Medicare Part D."

Transmittal 327 has an effective date of March 1 and an implementation date of April 16.

For more information about the signature requirements:
- read Transmittal 327