Medicare and the Chiropractic Practice, Part 11

"I thought my records were excellent," said Doctor Joe. "So I wasn't worried when I got the letter from CMS requesting copies of several patient records. I photocopied all the required records and sent them in. Imagine my shock when I got the results of the audit back from CMS! Here's what they said:

"Based on the medical documentation you submitted, we have found that some services you billed to Medicare were not reasonable and necessary, as dictated by the Medicare statute, or did not meet other Medicare coverage requirements. Of the 65 services reviewed, 61 were determined to be Not Medically Necessary - Reasons for Error: Missing or illegible provider signature. Medical record documentation must support the services billed according to Medicare guidelines, the medical necessity of the services, and be legible in order for the Medicare contractor to complete a fair review. In cases where the provider signature is illegible, a signature log or attestation statement should be sent. If the documentation is missing a provider signature, an attestation statement must be included with the submitted documentation."

"I immediately met with my staff and explained we would have to operate differently," Dr. Joe continued. "This is what we did: First, we checked our local Medicare contractor's Web site for the Chiropractic Local Coverage Determination (LCD) and signature policy. We also checked the policy from CMS and found this information:"

General Information

• Medicare requires that documentation of services provided to a patient is authenticated, with the appropriate provider's signature, in the patient health record.
• Handwritten and/or electronic signatures are acceptable.
• A signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.
• Stamp signatures are not acceptable.
• You must be familiar with your Local Coverage Determination (LCD) policy on authenticating records, as these policies will take precedence over the guidelines below.
• If your LCD does not have specific signature requirements regarding the legibility and presence of a signature, your contractor will follow the guidelines below to determine the identity and credentials of the signator.

Guidelines for Determining the Identity and Credentials of a Provider

• If, in the course of a patient health record review, a signature is found to be illegible, Medicare contractors will look for a signature log or attestation statement to determine the identity of the provider.
• A signature log includes a list of the typed or printed name(s) of the author(s) of the associated initials or illegible signature(s).
• The signature log can be included on the page where the initials or signature are present, or may be in a separate document.
• Although a reviewer may encourage providers to list their credentials in the signature log, a claim should be not denied if the log is missing a provider's credentials.
• All signature logs should be considered regardless of the date the log was created.

Attesting to a Signature's Validity

• Providers can include an attestation statement in the documentation they submit.
• Only the author of the medical record can attest to the record in question.
• Attestations will be accepted by reviewers regardless of the date of the attestation, 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 but cannot be used to "backdate" the plan of care.
• CMS recommends that, rather than backdating a patient health record, providers should use the signature authentication process explained below.
• In some situations, a provider may be contacted by a contractor and asked to submit an attestation statement or signature log. Providers will have 20 calendar days from the date of the contractor's call, or the date that the request letter is received by the post office, to provide the information.
• To be valid for Medicare medical review purposes, the attestation statement must be signed and dated and contain sufficient information to identify the beneficiary. An example is included below:

"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."

"I also accessed www.chirosummit.org, where I found a direct link to all the CMS requirements and a lot of other information about documentation," continued Dr. Joe. "With all this new information, I feel comfortable that, if audited again, I will pass with flying colors."

Resource

• Signature Guidelines for Medical Review Purposes. www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf

The members of the Summit Subcommittee on Documentation are Dr. Carl Cleveland III, Ms. Kim Driggers, Dr. Farrel Grossman, Ms. Donna Leiwer, Dr. John Maltby, Dr. Peter Martin, Ms. Susan McClelland, Dr. Ritch Miller, Dr. Frank Nicchi, Mr. David O'Bryon, and Dr. Frank Zolli. As with previous articles, Dr. Miller and Ms. Susan McClelland served as principal authors of this article, with assistance from committee members.