Medicare clarifies signature requirements

As of May 17, 2013 -  Medicare has clarified and updated the usage of rubber stamps for signature on medical documentation, as noted a transmittal from CMS (see links below)  The big “take-away” from this is that legible signatures need to be in place prior to billing services to Medicare.  To ensure compliance with Medicare, I would encourage providers to sign all orders and documentation in a timely manner.  Reimbursement is a critical factor for many practices, and this is an "easy" area to work on in your practice.  Be sure to audit and review your documentation for compliance.  Happy Coding!  L  : )

 GENERAL SIGNATURE REQUIREMENTS

http://www.cms.gov/transmittals/downloads/R327PI.pdf http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf http://www.cms.gov/ContractorLearningResources/downloads/JA6698.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R465PI.pdf  

The general signature requirements state that services that are provided to Medicare Beneficiaries need to be authenticated by the author, for medical review.  

If signatures are illegible or missing from medical documentation (other than orders), a signature log or attestation can be used to provide additional information to the reviewer.  However, orders without a signature will be disregarded during the claim review.

Signatures cannot be “captured” after the fact through signature logs or attestation.  Refer to the transmittal for detailed information on the signature log and attestation process. 

NOTE: The transmittal states: “If AC, MAC or CERT reviewers identify a pattern of missing/illegible signatures it shall be referred to the appropriate PSC/ZPIC for further development.”

NOTE: Stamp signatures are not acceptable  Per Transmittal 465, stamped signatures are acceptable only if the author has a physical disability and can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. The rubber stamp certifies that the provider has reviewed the document.  

NOTE: Any notation of “signature on file” also does not meet the signature requirements