(Medicare Program Integrity Manual)

Example: An illegible signature appears on a prescription.  The letterhead of the prescription  lists (3) physicians names.  One of the names is  circled.    X  5 Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by:  a signature log, or an attestation statement   X  6 Illegible signature NOT over a typed/printed name, NOT on letterhead and the documentation is UNaccompanied by: a signature log, or  an attestation statement   Example:     X 7 Initials over a typed or printed name  X  8 Initials NOT over a typed/printed name but  accompanied by: a signature log, or  an attestation statement   X  9 Initials NOT over a typed/printed name  UNaccompanied by: a signature log, or  an attestation statement    X 10 Unsigned typed note with providers typed name   X  Example:  John Whigg, MD     11 Unsigned typed note without providers typed/printed  name   X 12 Unsigned handwritten note, the only entry on the  page   X 13 Unsigned handwritten note where other entries on the  same page in the same handwriting are signed.  X  14 signature on file   X  E. Electronic Signatures   Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.  F. Electronic Prescribing   Electronic prescribing (e -prescribing) is the transmission of prescription or prescription-  related information through electronic media. E -prescribing takes place between a prescriber and dispenser, pharmacy benefit manager (PBM), or health plan. It can take place directly or through an e -prescribing network. With e -prescribing, health care professionals can electronically transmit both new prescriptions and responses to renewal requests to a pharmacy without having to write or fax the prescri ption. E -prescribing can save time, enhance office and pharmacy productivity, and improve beneficiary safety and quality of care.   A qualified e- prescribing system is one that meets the Medicare Part D requirements described in 42 CFR 423.160 (Standards for Electronic Prescribing).   1. E-Prescribing for Part B Medications (Other than Controlled Substances)   The MAC, CERT and UPIC reviewers shall accept as a valid order any Part B medications, other than controlled substances, ordered through a qualified e -prescribing system. For Medicare Part B medical review purposes, a qualified e -prescribing system is one that meets all 42 CFR 423.160 requirements. When Part B medications have been ordered through a qualified e -prescribing system, the reviewer shall NOT r equire the provider to produce hardcopy pen and ink signatures as evidence of a medication order.   2. E-Prescribing for Part B Controlled Substance  Medications   Historically, the Drug Enforcement Agency (DEA) has not permitted the prescribing of controlled substance medications through e -prescribing systems. Therefore, when reviewing claims for controlled substance medications, MAC, CERT and UPICs reviewers shall only accept hardcopy pen and ink signatures as evidence of a medication order. However, the DEA is  in the process of establishing requirements for electronic prescriptions for controlled substances. Refer to 21 CFR1300, 1304, 1306 and 1311 for further information.  3. E-Prescribing for Medications Incident to  DME   The MAC, CERT and UPICs reviewers shall accept as valid any e -prescribed order for medications incident to Durable Medical Equipment (DME), other than controlled substances. For the purpose of conducting Medicare medical review of medications incident to DME, a qualified e -prescr ibing system is one that meets all 42 CFR 423.160 requirements. When medications incident to DME have been ordered through a qualified e-prescribing system, the reviewer shall NOT require the provider to produce hardcopy pen and ink signatures as evidence  of a medication order.   G. Additional Signature Requirements for Durable Medical  Equipment, Prosthetics, Orthotics, & Supplies  (DMEPOS)   Refer to PIM chapter 5 for further details regarding additional signature requirements for DMEPOS.   H. Signature Dating  Requirements   For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and UPICs shall ensure that the documentation contains enough information for the  reviewer to determine the date on which the service was performed/ ordered.   Example: The claim selected for review is for a hospital visit on October 4. The ADR response is one page from the hospital medical record containing three (3) entries. The first entry is dated October 4 and is a physical therapy note. The second entry is a physician visit note that is undated. The third entry is a nursing note dated October 4. The reviewer should conclude that the physician visit was conducted on October 4.   I. Additional Documentation Request Language Regarding Signatures   The CERT contractor shall use language in its ADR letters reminding providers that the provider may need to contact another entity to obtain the signed version of a document. For example, a h ospital discharge summary in the physicians office files may be unsigned, whereas the version of the discharge summary in the hospital files should be signed and dated. MACs are encouraged to use such language in their letters. In addition, MACs, CERT and  UPICs have the discretion to add language to their ADRs stating that the provider is encouraged to review their documentation prior to submission, to ensure that all services and orders are signed appropriately. In cases where a reviewer finds a note with  a missing or illegible signature, the ADR may inform the provider that it should submit a signature log or signature attestation as part of the ADR response.   The following is sample language that reviewers may choose to use in certain ADRs:   Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamp signatures are not acceptable. Beneficiary identification, date of service, and provider of the service should be clearly identified on the submitted documentation.  The documentation you submit in response to this request should comply with these requirements. This may require you to contact the hospital or other facility where you provided t he service and obtain your signed progress notes, plan of care, discharge summary, etc.   If you question the legibility of your signature, you may submit an attestation statement in your ADR response.   If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing or illegible signature. This could lead the reviewer to determine that the medical necessity for the service billed has not been substantiated.   J. Potential Fraud Referrals   At any time, suspected fraud shall result in a referral to the UPIC for development. If MAC, RAC, SMRC or CERT reviewers identify a pattern of missing/illegible signatures, the reviewer shall refer to the appropriate UPIC for further development .  3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical Documentation  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, SMRC and UPICs, as indicated.   A. Amendments, Corrections and Delayed Entries in Medical  Documentation   All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented.  In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations the MACs, CERT, Recovery Auditors, SMRC and UPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described in section B below. The MACs, CERT, Recovery Auditors, SMRC and UPICs shall NOT consider any entries that do not comply with the principles listed in section B below, even if such exclu sion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.  B. Recordkeeping  Principles   Regardless of whether a do cumentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, SMRC and UPICs containing amendments, corrections or addenda must:   1. Clearly and permanently identify any amendment, correction or delayed entry  as such,  and  2. Clearly indicate the date and author of any amendment, correction or delayed entry, and   3. Clearly identify all original content, without deletion.  Paper Medical Records:  When correcting a paper medical record, thes e principles are generally accomplished by:  1. Using a single line strike through so the original content is still readable,  and  2. The author of the alteration must sign and date the revision.  Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the providers initials with their name. For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.   Electronic Health Records (EHR):  Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, SMRC and UPICs. Records sourced from electronic systems containing amendments, corrections or delayed  entries must:  a. Distinctly identify any amendment, correction or delayed entry; and b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.   If the MACs, CERT, SMRC or Recovery Auditors identify medical documentation with potentially fraudulent entries, the reviewers shall refer the cases to the UPIC and may consider referring to the RO and State Agency.  3.3.2.6 - Psychotherapy Notes  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, Recovery Auditors or UPICs, as indicated.   Psychotherapy notes are defined in 45 CFR164.501 as notes recorded by a mental health professional which document or analyze the contents of a counseling session and that are separated from the rest of a medical record. The definition of psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of administered treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms prognosis, ongoing progress and progress to date. This class of information does not qualify as psychotherapy note material. Physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes.  Under no circumstances shall the MACs, CERT, Recovery Auditors or UPICs request that a provider submit psychotherapy notes defined in 45 CFR 164.501. The refusal of a provider to submit such information shall not result in the automatic denial of a claim.   If the medi cal documentation includes any of the information included in the definition of psychotherapy notes in 164.501, as stated above, the provider is responsible for extracting information required to support that the claim is for reasonable and necessary services. MACs, Recovery Auditors, CERT or UPICs shall review the claim using the supporting documentation submitted by the provider. If the provider does not submit information sufficient to demonstrate that services were medically necessary, the claim shall be denied. Beneficiaries cannot be held liable for these denials unless they received proper liability notification before services were rendered, as detailed in CMS Pub. IOM, 100-04 chapter 30, 30.1.  3.3.2.7 - Review Guidelines for Therapy Services  (Rev . 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11)  This section applies to MACs.  Financial limitations on therapy services (therapy caps) were originally initiated by the Balanced Budget Act of 1997 and have been implemented at times without an exceptions process.  During a time when no exceptions process exists, contractors shall deny claims for Part B occupational, physical, and speech-language pathology therapy services, except for hospital outpatient therapy services, which exceed the therapy cap.  There is no therapy cap for hospital outpatient therapy services.  Automatic Process for Exception from the Therapy Cap