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American Academy of Family Physicians
Tuesday May 18, 2010

CMS giveth and Congress taketh away

In March (see "CMS extends cease fire on referring/ordering edits" on March 17), I reported that the Centers for Medicare & Medicaid Services (CMS) had extended the delay in implementation of new rules that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency had announced a delay in implementation of the new policy until Jan. 3, 2011. 

Unfortunately, what CMS gave, Congress and the President took away with passage of the Patient Protection and Affordable Care Act (PPACA). Amendments made by PPACA essentially mandate implementation of the new rules effective July 1, 2010. 

Or at least that is CMS's interpretation of the statute. CMS published an interim final rule with comment period in the Federal Register on May 5, 2010. The interim final rule implements several PPACA provisions that impact provider and supplier enrollment, ordering and referring, and documentation requirements.  CMS is accepting comments on the interim final rule through July 6, 2010. 

Related to the referring and ordering issue, CMS states that, effective July 1, 2010, it is requiring Medicare contractors to reject claims for selected items and services that are ordered or referred if the legal name(s) and national provider identifier(s) of the ordering/referring provider(s) are not on the claim or the ordering/referring provider does not have an approved enrollment record in PECOS. Affected items and services include durable medical equipment, prosthetics, orthotics, and supplies; home health items or services; and laboratory, imaging, and specialist services, where applicable. CMS is considering extending the provision to prescribed Part B drugs next year. 

CMS has provided an exception to the requirement that the referring/ordering provider have an approved enrollment record in PECOS in the case of an ordering/referring provider who has opted out of Medicare. Apparently, even CMS thought it was ludicrous to require someone to enroll in Medicare for purposes of ordering and referring when they had already opted out of Medicare for everything else.

What makes this particular provision so maddening is the difficulty so many physicians and others have actually enrolling through PECOS. Not only is it cumbersome, but it can often take months, and even making a simple address change through PECOS can lead to enormous headaches, based on some of the horror stories that I have heard.

For those that are interested, CMS is hosting a national provider and supplier conference call on Wed., May 19, from 3 to 5 p.m. ET. The focus of the call will be the interim final rule noted above. To participate, all you have to do is dial 1-800-603-1774 and reference Conference ID 61448973.  It may not change anything, but at least it's an opportunity to learn more on the subject and make your voice heard in the process.

Monday May 17, 2010

Signatures take on new significance

The Centers for Medicare & Medicaid Services (CMS) recently published new guidance on what constitutes a legible signature. An alphabet soup of auditors (MICs, RACs, CERTs and ZPICs) have been contracted to find and recover Medicare overpayments – like money paid for services when the documentation has no legible signature – so you should familiarize yourself with the rules.

For medical review purposes, Medicare requires that signatures for services provided or ordered be authenticated by the author with a handwritten or electronic signature. Stamped signatures and typed names without a signature are not acceptable.

If medical records are requested for review and you find that signatures are missing or illegible, do not add late signatures (beyond the delay that occurs during the transcription process). Instead, provide a signature log or attestation statement in support of the records.

A signature log contains the full name and credentials or title of everyone in the practice who might write in a medical record, their signature as they usually sign and any other forms of signature they might use (e.g., initials), and the date. If you don't want to create a comprehensive signature log for the practice, a simple one could be included as a separate entry on the actual page where the initials or illegible signature were used. (Tip: A list of commonly used abbreviations may provide additional support for your documentation, as these can be a source of confusion for auditors.)

An attestation statement is a signed statement that may be sent with unsigned medical documentation to attest that the services were performed and documented by the person who signs the attestation statement. This example is provided in the CMS guidance:

"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., MD] 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."

The attestation statement must contain sufficient information to identify the patient. Be sure to include the patient's name and insurance number.

Records or orders signed with a squiggle or what sometimes appeared to be the output from an ECG are giving way to electronic signatures generated by electronic health record systems, but even electronic signatures must be used correctly. Providers using electronic systems need to use software products and administrative procedures that protect against modification and comply with recognized standards and laws.

One final note from the CMS guidance: If reviewers identify a pattern of missing or illegible signatures, it will be referred to the appropriate program integrity contractor for further development.

Don't let something as easy to correct as a missing or illegible signature allow the auditors to take back money you earned.

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