September 20, 2010

One of the many reasons for which Medicare may deny your claims is the form of your electronic or handwritten signature. A number of ABC clients have recently had claims rejected allegedly because of missing information; follow-up by telephone has revealed that the anesthesiologist’s signature did not meet Medicare requirements.

The purpose of the signature requirements is to document that the anesthesiologist or other provider personally considered the service provided to be medically necessary. As a practical matter, the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), the comprehensive error rate testing (CERT) contractor, the safeguard contractors, and other auditors charged with reviewing claims "to minimize incorrect and inappropriate payments" have no truly effective tools for ensuring medical necessity without checking each claim individually. Regulating the physician’s signature is a proxy method.

Previously, language in the Medicare Program Integrity Manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. In March of this year, CMS published a Change Request (CR 6698) that updated Section 3.4.1.1.B of the PIM to read:

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable.

Handwritten signatures. If the medical record does not include a legible handwritten signature that clearly identifies the physician who provided or ordered the service, the guidelines for auditors indicate that the requirements may be met through use of a signature log or signature attestation statement.

• A signature log lists the typed or printed name of the provider associated with initials or an illegible signature. It may be helpful for providers to list their credentials on the signature log as well. Signature attestation statements are another way for providers to authenticate the medical record. The attestation must be signed and dated by the author of the medical record entry at issue and must sufficiently identify the beneficiary who was provided or ordered services.
• A signature attestation statement from the author of a medical record will also be considered if the physician’s signature is missing from the documentation at issue. This requirement applies to all medical documentation missing a signature other than an order. If the physician’s signature is missing from an order, contractors are instructed to disregard the order in the review of the claim. When the signature is illegible or missing, the guidelines require the contractor to contact the billing provider or organization to request that an attestation statement or signature log be submitted.

Electronic signatures. Electronic e signatures e in the form of a digitized signature, electronic signature or digital signature are all acceptable. Digitized signatures are electronic images of the actual handwritten signature. Electronic signatures should contain the date, timestamp and a printed statement (such as "electronically signed by"). Digital signatures are an electronic signature typically generated by special encrypted software that allows for sole usage.

Electronic and digital signatures are not the same as 'auto-authentication' or
'auto-signature' systems, some of which do not mandate or permit the provider to review an entry before signing.

Indications that a document has been 'Signed but not read' are not acceptable.

The Medlearn Matters® article associated with the Change Request contains many examples of acceptable and unacceptable signatures. One of the MACs, Palmetto GBA, translated the Medlean Matters information into tabular form, which we reproduce below.

We hope that the above information will be helpful to you in avoiding Medicare denials and audits of claims for lack of the requisite signature.

Sincerely,

Tony Mira
President and CEO


If you have any questions or would like additional information please call 517-787-6440 x 4113, send an email to info@anesthesiallc.com, or visit our website at www.anesthesiallc.com/.