If an order is taken verbally and sent to the physician for a signature and date, there are two documents: the verbal order and the written order with the physician's signature and date.If a beneficiary comes in with a prescription containing all of the elements of a detailed written order, then one document is on file.Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed.Reimbursement shall be based on the specific utilization amount only.There must be documentation to show the verbal order was received prior to dispensing the item.Example: The treating physician calls the supplier and prescribes a glucose monitor with a verbal order.The following are various questions and answers regarding signature requirements for medical and CERT documentation. The signature requirements described in CMS Change Request (CR) 6698 were effective March 1, 2010. Do signature requirements also apply to prescription signatures? Also, CMS permits the use of a rubber stamp for signature if the author has a physical disability and can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. The rules in 42 CFR 410 and IOM Medicare Benefit Policy Manual, Publication 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 by the treating physician (e.g. Only when it is clear that an individual document extends to multiple pages and that the entire document is then authenticated, would a signature on a single page suffice for other pages as well. After a service has been rendered, what amount of time is acceptable to Medicare for the doctor to sign the notes? Noridian expects that in most cases the notes would be signed at the time services are rendered. See CMS Internet Only Manual (IOM), Medicare Program Integrity Manual, Publication 100-08, Section 22.214.171.124 . No attestation or signature log is required as the printed name will suffice. Should we send the attestation statement with an appeal? To expedite the appeals process, it is advisable to send the attestation statement, if needed. What are acceptable electronic signature notations? Submit final copies and not preliminary or draft copies of documentation. How do I know if my electronic software work flow meets the electronic signature qualifications? Check with your technical staff or software vendor to verify software/hardware meets or exceeds industry standards and are in compliance with CMS instruction. As an example, orders for clinical diagnostic lab tests are not required to be signed.
The detailed description in the written order may be either a narrative description or a brand name/model number. Signatures must comply with the CMS signature requirements outlined in PIM 126.96.36.199. A prescription is not considered as part of the medical record.If documentation is requested the signature log must then be sent along with the appropriate notes. Can the signature log be faxed or does Medicate need the original signatures? The requirement for Medicare validation is that we must be able to connect the provider of service to the records or notes.The electronic signature component must be able to be authenticated and confirmed by the provider of service.It must contain: For the "Date of the order" described above, use the dispensing order date i.e., the date the supplier was contacted by the prescribing physician (for verbal orders) or the date entered by the prescribing physician (for written dispensing orders).Additional order date instructions: In some cases, the prescribing physician may specify a future start date for therapy that is different from the date of the order.
Other than the lab tests, is a doctor required to sign every page of the documentation? All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. Without the signed order by the physician, the therapist will not be reimbursed. When a signature is illegible, can a stamp be used to supplement the illegible signature? A rubber stamp that has a "printed" name can be used but the practitioner must sign and date the document. Examples of acceptable electronic signatures are, but not limited to: Note: ‘Signed but not read' is not acceptable When documentation is requested by Medical Review, or CERT, ensure the documentation has been signed by the provider before sending the appropriate records. Medicare would expect the order, notes, and POC to have signatures authenticated by a completed signature attestation form or signature log. Is it appropriate verbiage on electronic health records if it states "authenticated by" or "reviewed by, or "approved by" to meet the requirements for Medicare guidelines? Submit final copies, not preliminary or draft copies, of documentation. If a scribe documents charts for the doctor, can he/she sign, with initials or is a full name with credentials required? Note: There are some circumstances for which an order does not need to be signed.