Observation Deck

Securing the Signature

Knowing the specifics offers some audit relief.

• By Kelly Riley
• Nov 01, 2010

Earlier this year word quickly spread throughout the healthcare world that CMS intended to more rigorously enforce the rules regarding legible signature requirements. This applies to the physician/practitioner orders for medical care and products, as well as any supporting documentation. For many, the initial response was “No one can ever read a doctor’s signature.” While that might be the case, proper penmanship was not what CMS was after. Perhaps there would have been less confusion had they used the term previously contained within the Program Integrity Manual: “legible identifier.” The forging of a signature is simply easier to do the more indiscriminate it is. By insuring the validity of the author (or prescriber) there is protection of thebeneficiary, the physician and, in our case, legitimate HME providers.

It is common knowledge that audits are on the rise throughout all health care, and HME is no exception. With this in mind it is good to know what rules the various audit contractors need to play by. Those rules are communicated in Change Request (CR) 6698, which was published earlier this spring. According to CR 6698, Medicare administrative contractors, the comprehensive error rate testing contractor (CERT) and recovery audit contractors (RAC) are tasked with measuring, detecting and correcting improper payments in the fee-for-service Medicare program.

Results of a recent CERT audit specific to code E0601 (CPAP) revealed that in areas of both detailed written orders and medical necessity documentation (clinical evaluations) signature issues came up as problematic. The following are examples that CMS provides of when the signature requirements are met:

• Legible full signature
• Legible first initial and last name
• Illegible signature over a typed or printed name
• Illegible signature where the letterhead or other information indicates the identity of the prescribing physician. For example, an illegible signature appears on a prescription and the letterhead of the prescription lists 3 three physician’s’ names. The name of the prescribing physician is circled.
• 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.
• Initial over a typed or printed name
• Unsigned handwritten note where other entries on the same page in the same handwriting are signed.

In contrast, here are examples of when signature requirements are not met:

• Illegible signature not over a typed/printed name, not on letterhead and the documentation isn’t paired with a signature log or attestation statement.
• Initials NOT over a typed/printed name unaccompanied by a signature log or an attestation statement.
• Unsigned handwritten note, the only entry on the page.
• Unsigned typed note with physician’s typed name.
• “Signature on file”

It is important to check all supporting documents that are being sent in due to a request for ADR. An area recently discovered is, unsigned PSGT reports. For years our industry has been faced with being asked to set up CPAP equipment prior to the final signed sleep study being available. Once we verified that the patient met the medical necessity requirements (AHI, RDI) we generally filed the preliminary copy away.

If that is the copy that is then sent to the CERT or other contractor, it probably still is not signed. This is when it is good to know the rules the contractors must play by, especially some time lines that are to be provided to the supplier. Some of the key points are:

• If the signature is missing from an order, ACs, MACs, PSCs, ZPICs and CERT shall disregard the order during the review of the claim.
• If the signature is missing from any other medical documentation, ACs, MACs, PSCs, ZPICs and CERT shall accept a signature attestation from the author of the medical record entry.
• Reviewers may encourage providers to list their credentials in the log, but reviewers shall not deny a claim for signature logs without credentials.
• Reviewers shall consider all submitted signature logs regardless of date.
• Reviewers shall not consider attestation statements where there is NO associated medical record entry.
• Reviewers shall not consider attestation statements from someone other than the author of the medical record entry in question (even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements).
• Reviewers shall consider all attestations that meet the above requirements regardless of the date the attestation was created, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date.
• In the situations where the guidelines in the PIM indicate “signature requirements met,” the reviewer shall consider the entry.
• In situations where the guidelines in the PIM indicate “contact billing provider and ask a non-standardized follow up question,” the reviewer shall contact the person or organization that billed the claim and ask them if they would like to submit an attestation statement or signature log within 20 calendar days. The 20 20-day time frame begins once: 1) the contractor makes an actual phone contact with the provider, or 2) the date the request letter is received by the post office.
• If the biller submits a signature log or attestation, the reviewer shall consider the contents of the medical record entry. In cases where the reviewer contacts the provider, the time frame for completing the review is extended for an additional 15 days.

It becomes apparent that the rules for the reviewer are fairly specific and can provide some relief to the HME supplier in trying to secure acceptable orders and supporting documents when subjected to an audit.

This article originally appeared in the November 2010 issue of HME Business.