Signing and dating doctors orders
The first publication is the "Improper Medicare Fee for Service Payments Report of November 2009." This report details the type and percentage of errors found in claims as determined by reviews performed under the CERT (Comprehensive Error Rate Testing) program.Page 9 of this document describes changes in what is acceptable and not acceptable for documentation to support the medical necessity of services provided.Want to receive articles like this one in your inbox? Let’s take a closer look at the updated provider signature guidelines for labs and diagnostic testing. Cassano, CPC Providers must understand the revisions to signature guidelines outlined in Med Learn Matters article 6698 and Transmittal 327 in the Medicare Program Integrity Manual, which were revised on April 26 to include additional clarifying language from CR 6698 and are retroactive to March 1 in order to satisfy the November 2010 reporting period.Initials are not acceptable as signatures without further documentation (attestation, signature log, typed or printed name next to the initials, etc.) This transmittal also defines acceptable electronic signatures for e-prescribing.To assess the impact of these two documents, providers should conduct their own review of order signatures to see if they meet these new requirements.
However, if there is an unsigned order for a clinical diagnostic test, there must be documentation by the physician, such as a progress note, that shows that the physician intended for the test to be performed. CMS states that providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead use the signature authentication process.
Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment.