LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2011-04 Comprehensive Error Rate Testing (CERT) Signature Requirements

FACT SHEET

Comprehensive Error Rate Testing (CERT) Signature Requirements
  • This fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to signature requirements and provides information on the documentation needed to support a claim submitted to Medicare for medical services.The Centers for Medicare & Medicaid Services (CMS) developed the CERT Program to produce a national Medicare Fee-For-Service (FFS) error rate, as required by the Improper Payments Information Act. CERT randomly selects a small sample of Medicare FFS claims and reviews those claims and medical records from providers/suppliers who submitted the claims for compliance with Medicare coverage, coding, and billing rules.In order to accurately measure the performance of the Medicare claims processing contractors and to gain insight into the causes of errors, CMS calculates both a national Medicare FFS paid claims error rate and a provider compliance error rate. The results of these reviews are published in an annual report and semi-annual updates.CMS strives to eliminate improper payments in the Medicare Program to maintain the Medicare trust funds and protect patients.
Signature Requirements Questions & Answers

Question:

  • What is required for valid signature?

Answer:

  • In order for a signature to be valid, the following criteria must be met:
    •Services that are provided or ordered must be authenticated by the
    ordering practitioner;
    •Signatures are handwritten or electronic (stamped signatures are not
    acceptable); and
    • Signatures are legible.
    Reference: CMS “Medicare Program Integrity Manual? (Publication [Pub.]
    100-08), Chapter 3, Section 3.4.1.1.D

Question:

  • What should I do if I haven’t signed an order or medical record?

Answer:

  • You may not add late signatures to medical records (beyond the short delay that occurs during the transcription process). Medicare does not accept retroactive orders. If the practitioner’s signature is missing from the medical record, submit an attestation statement from the author of the medical record. Your contractor may offer specific guidance regarding addenda to medical records. If the order is unsigned, you may submit progress notes showing intent to order the tests. The progress notes must specify what tests are being ordered. A note stating “Ordering Lab? is not sufficient. If the orders and the progress notes are unsigned, your facility or practice will be assessed an error, which may involve recoupment of an overpayment.Reference: CMS “Medicare Program Integrity Manual? (Pub. 100-08), Chapter 3, Section 3.4.1.1.D

Question:

  • What if the physician signs the order or progress note, but the signature is not legible?

Answer:

  • You may submit a signature log or attestation statement to support the identity of the illegible signature. If the original record contains a printed signature below the illegible signature, this may be accepted.Reference: CMS “Medicare Program Integrity Manual? (Pub. 100-08), Chapter 3, Section 3.4.1.1.D.1

Question:

  • What is a signature log?

Answer:

  • A signature log is a typed listing of the provider(s) identifying their name with a corresponding handwritten signature. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation.Reference: CMS “Medicare Program Integrity Manual? (Pub. 100-08), Chapter 3, Section 3.4.1.1.D.1.a

Question:

  • What if my provider does not have a signature log currently in place?

Answer:

  • On behalf of a health care provider, you may create a signature log at any time, and Medicare Contractors will accept all submitted signature logs regardless of the date on which they were created.

Question:

  • Am I able to attest to my signature?

Answer:

Question:

  • Can I avoid delays in the completion of claims review by sending a signature log or signature attestation with my documentation?

Answer:

  • CMS encourages you to submit a complete medical record with appropriate
    signature documentation initially to avoid delays in the completion of the review. This would include a signature log or attestation if needed.

Question:

  • Do my signatures need to be dated?

Answer:

  • Documentation must contain enough information to determine the date on which the service was performed/ordered. If the entry immediately above or below the entry is dated, medical review may reasonably assume the date of the entry in question.Reference: CMS “Medicare Program Integrity Manual? (Pub. 100-08),
    Chapter 3, Section 3.4.1.1.J

Question:

  • What are the guidelines for using an electronic signature?

Answer:

  • The guidelines for using an electronic signature are:
    • Systems and software products must include protections against
    modification, and you should apply administrative safeguards that
    correspond to standards and laws;
    • The individual whose name is on the alternate signature method
    and the provider bears the responsibility for the authenticity of the
    information being attested to;
    • Physicians are encouraged to check with their attorneys and malpractice
    insurers in regard to the use of alternative signature methods;
    • Part B providers must use a qualified electronic prescribing
    (e-prescribing) system; and
    • Prescriptions for drugs incident to Durable Medical Equipment (DME)
    must be made via a qualified e-prescribing system.
    Reference: CMS “Medicare Program Integrity Manual? (Pub. 100-08),
    Chapter 3, Section 3.4.1.1
Resources

CMS guidance regarding signature requirements is available through the following
resources:
For Medicare Learning Network’s® MLN Matters® Article MM6698, “Signature Guidelines for Medical Review Purposes,? visit on the CMS website.
For Medicare’s signature requirements, refer to the CMS “Medicare Program Integrity Manual? at on the CMS website.