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CMS Clarifies Signature Requirements

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6698 to clarify how Medicare claim review contractors review claims and medical documentation submitted by providers. This clarification included an outline of new rules for signatures and added language for e-prescribing.

The previous language in the Program Integrity Manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. CR 6698 updates these requirements to require that every service provided or ordered be “authenticated by the author” by handwritten or electronic signature; stamp signatures are generally unacceptable.

CR 6698 also provides some exceptions to the signature requirement. First, facsimiles of original written or electronic signatures are acceptable for certifications of terminal illness for hospice. Second, there are other circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed, but there must be medical documentation by the treating physician that s/he intended the clinical diagnostic test to be performed. The documentation showing intent must be authenticated by the author with a handwritten or electronic signature. Finally, other regulations and CMS instructions regarding signatures take precedence. For example, if the NCD, LCD, and CMS manuals have specific signature requirements, those signature requirements take precedence. However, if these are silent as to signature requirements, the reviewer should follow the guidelines set forth in CR 6698.

In the event that the NCD, LCD, and CMS manuals are silent on whether the signature be legible or present, the Medicare contractors must apply the specific requirements set forth in CR 6698 in reviewing the signature. For example, contractors must determine if there are reasons for denial of the claim unrelated to the signature requirements. If there are, the reviewer does not have to proceed to signature authentication. In addition, if the signature is illegible, the contractors must 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, then the contractors must disregard the order during the review of the claim. If the signature is not dated, the reviewer must review to ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed or ordered.

In addition, CR 6698 outlined clarifications for electronic prescribing. E-prescribing can save time, enhance office and pharmacy productivity, and improve patient safety and quality of care. Through e-prescribing, healthcare professionals can electronically submit both new prescriptions and responses to requests for renewal to a pharmacy without having to write or fax a prescription. CR 6698 specified some key points regarding e-prescribing: (1) reviewers will accept as a valid order any Part B drugs, other than controlled substances, ordered through a qualified e-prescribing system (defined as one that meets all requirements set forth in 42 CFR 423.160); (2) e-prescribing is not permitted for the prescription of controlled substances, and as such reviewers will only accept hardcopy pen and ink signatures as evidence of a drug order when reviewing claims for controlled substance drugs; and (3) reviewers must accept as a valid order any drugs incident to DME, other than controlled substances, ordered through a qualified e-prescribing system.

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