CMS Updates Signature Requirements

BALTIMORE — Last week, CMS updated its signature guidelines for medical review.

Change Request 6698, issued March 16, adds language covering e-prescribing and states that for medical review purposes, Medicare requires that every service provided or ordered be “authenticated by the author” — vs. the previous requirement for a “legible identifier” — in the form of a handwritten or electronic signature; stamp signatures are not acceptable.

Other than controlled substances, reviewers should “accept as a valid order” any drugs incident to DME ordered through a qualified e-prescribing system (defined as one that meets all 42 CFR 423.160 requirements). “When drugs incident to DME have been ordered through a qualified e-prescribing system, the reviewer shall NOT require the provider to produced hardcopy pen and ink signatures as evidence of a drug order,” CMS said.

The change request directs providers to Chapter 5 of the Program Integrity Manual for further details regarding additional signature requirements for DMEPOS.

In the new instruction, CMS also added some exceptions to the signature requirement. In addition to allowing facsimiles of original written or electronic signatures for hospice certification, the agency said “there are some circumstances for which an order does not need to be signed,” such as for clinical diagnostic tests that have medical documentation showing the physician intended that the test be performed.

The agency said when other regulations and CMS instructions, such as national and local coverage determinations and CMS manuals, have specific signature requirements, those requirements take precedence. When those sources have no instructions on signatures, the change request sets out guidelines for reviewers that address illegible and missing signatures, signature logs and signature attestation statements.

If the signature is illegible, according to the change request, reviewers should consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry. If the signature is missing from an order, medical reviewers should disregard the order in review of the claim. If the signature is missing from any other medical documentation, reviewers should accept a signature attestation from the author of the medical record entry.

In the case of a signature log that lists the typed or printed name of the author associated with initials or an illegible signature, 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,” CMS noted.

An attestation statement “must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary” in order to be considered valid, CMS said. The change request includes a sample attestation statement providers can use and gives instructions for when such a statement may not be used.

The instruction also gives a list of when an illegible signature meets the signature requirement, and when it doesn’t. For example, initials over a typed or printed name meet the requirement; initials not over a typed or printed name and unaccompanied by either a signature log or an attestation statement don’t. An unsigned handwritten note where other entries on the same page are signed in the same handwriting meets the requirement; an unsigned handwritten note that is the only entry on the page doesn’t.

In situations where the signature requirement is unmet, the reviewer should contact the organization that billed the claim to ask if they would like to submit an attestation statement or signature log within 20 calendar days, CMS said. In cases where the reviewer contacts the provider, the time frame for completing the review is extended for an additional 15 days.

The new guidelines will take effect on April 16.

Read Change Request 6698.