(Medicare Program Integrity Manual)

Totality of the Record  All DMEPOS items require a Standard Written Order (SWO) from the treating practitioner as a condition of payment. Medicare contractors shall consider the totality of the medical r ecord when reviewing for compliance of the SWO elements. This will allow contractors to account for the dynamic nature of electronic medical record documentation systems, and give them additional discretion when they believe the entirety of the record demo nstrates compliance with our order requirements. For example, a contractor may nonetheless support payment when an order has a missing or flawed element that is clearly documented elsewhere in the record.   Contractors acting as a secondary reviewer shall g rant deference to the initial reviewers discretion, if such an initial decision resulted in a reasonably prudent decision that aligns with Medicare coverage and coding instructions.  3.3.2.2 - Absolute Words and Prerequisite Therapies  (Rev. 10365; Issued: 10 -02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.   The MACs, CERT, Recovery Auditors, and UPICs shall not deviate from coverage provisions if absolute words such as never or only if are used when making claim determinations where a regulation, CMS ruling, NCD, LCD, or MAC policy article exists. In these cases, reviewers shall not make any exceptions or give individual consideration.   Requirements for  prerequisite therapies shall be followed when deciding whether to cover a service if listed in coverage provisions in interpretive manuals (e.g., conservative treatment has been tried, but failed).   3.3.2.3 - Mandatory Policy Provisions (Rev. 10365; Iss ued: 10 -02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, Recovery Auditors, CERT and UPICs, as indicated.   CERT contractors select claims for review on a random basis and do not select claims that are suspect. The CERT r eviewers shall review every line on the randomly selected claim that affects payment to determine if the following types of requirements are met:    Coding requirements;   Benefit category  requirements;   The reasonable and necessary requirements of the NCDs and LCDs, among others.   The MACs and UPICs select claims to prevent or identify an improper payment. They are only required to review the suspect line and not every line on the selected claims. The selected line does not need to be completely reviewed. Along with reviewing the line for coding accuracy, the MACs should review for medical necessity if the provider has been notified that both types of review will occur. The UPICs shall use discretion in notifying the provider.   3.3.2.4 - Signature Requirements  (Rev. 11032; Issued: 09- 30-21; Effective: 10 -12-21; Implementation: 11 -10-21)  This section is applicable for Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), Supplemental Medical Review C ontractors (SMRCs), Comprehensive Error Rate Testing (CERT), and Recovery Audit Contractor (RACs), as indicated.   For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the ca re of the beneficiary in accordance with Medicares policies. For example, if the physicians authenticated documentation corroborates the nurses unsigned note, and the physician was the responsible party per Medicares payment policy, medical reviewers w ould consider signature requirements to have been met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.   NOTE: Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physicians/non- physician practitioners (NPPs) signature on a note indicates that the physician/NPP affirms the note adequa tely documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non- physician practitioner on the note.  Reviewers shall not deny claims for items or services because a scribe has not signed/date d a note.   EXCEPTION 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.   EXCEPTION 2: There are some circumstances for which an order does not need to be signed. For example, or ders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100- 02 chapter 15, Section 80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a prog ress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.   EXCEPTION 3: Other regulations and the CMS instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS  manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed below to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases  where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.   EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 197 3 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the docu ment.   NOTE: Conditions of participation (COP) are not conditions of payment.  If MAC and CERT reviewers find reasons for denial unrelated to signature requirements, the reviewer need not proceed to signature authentication. If the criteria in the relevant Medicare policy cannot be met but for a key piece of medical documentation that contains a missing or illegible signature, the reviewer shall proceed to the signature assessment.   Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process. The signature authentication process described below should also be used for illegible signatures.  A. Handwritten Signature   A handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance or obligation.   If the signature is illegible , MACs, UPICs, SMRC, and CERT shall consider evidence in a signature log, attestatio n statement, or other documentation submitted to determine the identity of the author of a medical record  entry.   If the signature is missing from an order, MACs, UPICs, SMRC, and CERT shall disregard the order during the review of the claim (e.g., the reviewer will proceed as if the order was not  received).    If the signature is missing from any other medical documentation (other than an order), MACs, UPICs, SMRC, and CERT shall accept a signature attestation from the author of the medical record entry.  B. Signature  Log  Providers will sometimes include a signature log in the documentation they submit that lists the typed or printed name of the author associated with initials or illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document. Reviewers should encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials. Reviewers shall consider all submitted signature logs regardless of the date they were created. Reviewers are encouraged t o file signature logs in an easily accessible manner to minimize the cost of future reviews where the signature log may be needed again.   C. Signature Attestation  Statement   Providers will sometimes include an attestation statement in the documentation they submit. In order to be considered valid for Medicare medical review purposes, 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.   Should a provider  choose to submit an attestation statement, they may choose to use the following statement:  I, [print full name of the physician/practitioner], hereby attest that the medical record entry for _[date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.   Although this format is acceptable, the CMS currently neither requires nor instructs providers to use a certain form or format. A  general request for signature attestation shall be considered a non- standardized follow -up question from the contractors to the providers. However, since no form for signature attestation has been approved by the Office of Management and Budget (OMB), the  contractors should not give the providers any standard format on which to submit the attestation. Once the OMB has assigned an OMB Paperwork Reduction Act number to this attestation form, its use will be mandatory.   Note: The MACs and CERT shall NOT consi der 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 sam e group, one should 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. For example, if a policy states the physician must sign the plan of care before therapy begins, an attestation can be used to clarify the identity associated with an illegible signature. However, such attestation cannot be used to backdate the plan of care.   D. Signature  Guidelines   The guidelines below will assist in determining whether to consider the signature requirements met:   In the situations where the guidelines indicate signature requirements  met, the reviewer shall consider the entry.    In situations where the guidelines 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 if the billing entity would like to submit an attestation statement or signature log within 20 calendar days. The 20 day timeframe begins on the date of the telephone contact with the provider  or on the date the request letter is received by the provider. If the biller submits a signature log or attestation, the reviewer shall consider the contents of the medical record  entry.    In cases where a reviewer has requested a signature attestation or log,  the time for completing  the review  is extended  by 15 days. This extension starts upon receipt of the signature attestation or  log.   The MACs, CERT and UPICs shall document all contacts with the provider and/or other efforts to authenticate the  signature.   Note: The MACs, CERT and UPICs shall NOT contact the biller when the claim should be denied for reasons unrelated to the signature requirement.         Signature Requirement Met Contact billing provider and ask a non - standardized follow up question  1 Legible full signature  X  2 Legible first initial and last name  X  3 Illegible signature over a typed or printed name   Example:  John Whigg, MD   X  4 Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signatory.   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