The Centers for Medicare & Medicaid Services (CMS) requires that any Medicare service provided or ordered must be authenticated by the author.
Physicians Must Sign Notes Before Billing
By William C. Fiala, Fiala Analytical Services, Inc. Contributing Author
Most folks have heard some version of a pejorative joke about a Chinese laundry wherein the expression “no tickee, no washee” appears. The dialect story appears to have been published just after the turn of the twentieth century in Uncle Josh's Punkin Centre Stories in 19031. At the turn of the twenty-first century, at least in regards to CMS payment, “tickee” can be substituted for signature and “washee” for payment—no signature, no payment.
As government officials in Washington check the limo seats for spare change to augment their budgets, signatures, or lack thereof, have drawn attention as a potential source of take-backs.
“One person told me that the lack of clear signatures (e.g. legibly signed, dated orders) could represent nearly $6 billion in recoupment of Medicare funds because they will consider a service as being provided without an order if the signature is absent or illegible.” says Cheryl Servais, vice president of compliance and privacy officer at Precyse Solutions.2
The concept of order transcends to medical necessity. For example, the old LMRP, now NCD, for vitamin B12 injections indicates that medical necessity is established “only after a deficiency has been documented by serum assay.”3 If the lab results show B12 levels below 100pg/mL, but the results are not signed, there is no medical necessity because CMS assumes the physician did not order and review the lab work, and the injection is not reimbursable. Attorney Nancy Miller, writing in the August 2002 issue of Physician’s News Digest, reminds us if services or equipment are ordered from other vendors, there needs to be a signature.
A certificate of medical necessity (CMN) is required for Medicare reimbursement for 14 types of DME and supplies. Section B of the CMN must be completed by the treating physician (or a nonphysician clinician or a physician employee) because this section documents medical necessity. While filling out these forms is a chore, section D must be personally signed by the treating physician or midlevel practitioner to attest the accuracy of the information. Signature stamps and date stamps are not permissible.4
In short, whether they pertain to internal practice activities or external vendors, all entries to the clinical record need to be signed.
As above, signature stamps are not acceptable. The standard for what constitutes a signature is pretty clear. Palmetto GBA claims are denied by the CERT Review Contractor due to one of four “not acceptable” signature reasons including:
Illegible, unrecognizable handwritten signatures or initials;
Unsigned ‘typewritten’ progress notes with a typed name only;
Unverified or unauthorized electronic signatures;
No indication of the rendering physician/practitioner.5
Note the last item, again, every entry to the record needs signed—if the progress note is not signed, the CERT contractor is empowered to deny the claim, as without a signature there is no rendering provider. The basis for the denial is found in CMS’s Interpretive Guidelines §482.24(c)(1): “all entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.” “Authenticated” means signed.
Bottom line: all entries to the clinical record need to be signed.
1 See Wolfgang Mieder in Western Folklore 55:1(January 1996)1-40 for a lengthy discussion.
2 DeOrio, Lee, “No More Squiggle Room on Signatures,” For the Record, May 10, 2010, p 3.
3 See http://www.wpsmedicare.com/part_b/policy/active/local/l30145_inj004.shtml.
4 See http://www.physiciansnews.com/law/802.miller.html.
5 “Palmetto GBA Comments on Comprehensive Error Rate Testing (CERT),” Northern Ohio Physician, March/April 2010, p. 10.