Disclaimers. Responsibility for correct claims submission lies with the provider of services.

Transcription

1 CMS Signature Requirements Hand Written or Electronic Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach and Education March 28, 2013 Disclaimers This resource is not a legal document. The presentation was prepared as a tool lto assist providers and was current at the time of creation. Responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited; providers are encouraged to share this education with staff. American Medical Association (AMA) Current Procedural Terminology (CPT ) Copyright Statement. CPT copyright 2013 and trademark of the AMA. All Rights Reserved. 2 1

2 Topics Medical Review Program CMS Signature Requirements Comprehensive Error Rate Testing (CERT) CMS and Cahaba GBA Resources 3 Medical Review Reduce payment errors by identifying and addressing billing errors related to coverage and coding of services Data Driven Indentify vulnerabilities Identify questionable billing patterns Prevent and/or address provider errors Reduce paidclaims errorrate rate Publish Local Coverage Determinations (LCD) Medical Review and Education CMS Overview: Statistics Data and Systems/Monitoring Programs/Medical Review/index.html?redirect=/MedicalReviewProcess/ Program Integrity Manual Pub Medical Review Program: and Guidance/Guidance/Manuals/downloads/pim83c03.pdf 4 2

3 Local Coverage Determination Local Coverage Determinations (LCDs) Developedby local contractor Address local coverage Cahaba GBA LCD Signature Statement Documentation must support CMS 'signature requirements' as described in the Medicare Program Integrity Manual (Pub ) Chapter 3 Cahaba GBA LCDs: b/medical review/local coverage determinations lcds and articles/ Medicare Coverage Database: coverage database/overview and quick search.aspx?list_type=ncd 5 CMS Signature Requirements Change Request 6698: Signature Requirements for Medical Review Purposes For medical review purposes, Medicare Mdi requires that t services provided/ordered be authenticated by the author Hand written or Electronic signature Stamp signatures are not acceptable Change Request 6698 March 16, 2010: and Guidance/Guidance/Transmittals/Downloads/R327PI.pdf Complying with Medicare Signature Requirements: CERT Fact Sheet revised and Education/Medicare Learning Network MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN pdf Program Integrity Manual Pub : Chapter 3, Section : and Guidance/Guidance/Manuals/Downloads/pim83c03.pdf 6 3

4 Handwritten Signature Signature Definition A handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation Signature authentication process apply Change Request Electronic Signatures Recognize the potential for misuse or abuse Apply administrative procedures; recognized standards and laws Ensure system and software products are protected The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information attested to in the medical record Checkwith legal representation regarding alternative signature methods Change Request

5 Signature Requirements Exception 1: Hospice Certifications of terminal illness Facsimile of original written or electronic signatures Exception 2: Clinical diagnostic tests Orders not required to be signed No signed order; document intent for test Exception 3: Relevant regulations silent Other regulations and CMS instructions (NCD, LCD and CMS manuals)regardingsignaturestake signatures take precedence For medical review purposes: Signature authentication process, if relevant guidelines are silent Change Request Timeliness of Signatures Signature Requirements Providers should not add late signatures to medical record beyond theshort delay that occurs duringthetranscription process the short delay that occurs during the transcription process Use signature authentication process Dating a Record Documentation must contain enough information to determine the date 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 Change Request 6698 The State Operations Manual Appendix A Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (c) Standard Content of Record: and Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 10 5

6 Signature Log A signature log lists the typed or printed name of the author associated with initials or an illegible signature The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document Reviewers may encourage providers to list their credentials in the log However, reviewers shall notdenya claim for a signature log that is missing credentials Reviewers shall consider all submitted signature logs regardless of the date they were created Change Request Signature Attestation Statement An attestation statement must be signed and dated by the author of the medical record entry and; An attestation statement must contain sufficient information to identify the beneficiary An attestation statement must have documentation that is associated with the medical record entries and the author of record in question In cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements Reviewers will consider all attestations that meet the guidelines regardless of the date the attestation was created, 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 Change Request

7 Signature Attestation Statement CMS is neither requiring nor instructing providers to use a certain form or format. Providers may choose to use this CMS example for an attestation letter: 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 dthat any flifi falsification, i omission, i or concealment of material fact may subject me to administrative, civil, or criminal liability. CMS is neither requiring nor instructing providers to use a certain form or format Change Request Physician s Signature Operative Procedure Name: Smith, James Sex: M Room#: 345 Admitting Physician: Tom Doe, M.D. Page 1 Medical Documentation _Tom Doe, 12:26 pm_ Tom Doe, MD M.D. I authorize my name to be automatically affixed to this report signifying I have dictated this report and reviewed it accordingly. TD/TD DD: 10/02/ :25:14 DT: 10/02/ :47:10 (Revised March 28, 2013) 14 7

8 Physician s Signature Patient: William Smith Date of Birth: 10/15/35 Historian: Self Visit type: Office Reason for visit Chronic problem(s) Review of Systems Past, Family and Social Histories Physical Exam Clinical Assessment/Plan Medications (added or renewed this visit) Office Service End of report statement: I was available at the time of service and agree with the plan of care on January 31, Supervising Provider: James Doe, M.D :12 pm Document electronically signed by: James Doe, M.D. January 31, :12PM (Revised March 28, 2013) 15 Medical Review Errors Signature Errors Signatures are illegible or no provider signature No identifying signatures of performing providers Medical Necessity Errors / Insufficient Documentation Services determined not medically necessary Insufficient documentation/notes not signed Medical records not submitted for review Incorrect Coding of Services Documentation did not support code(s) billed 16 8

9 Ambulance: Beneficiary Signatures CMS Beneficiary Signature Requirements Medicare Benefit Policy Manual Chapter 10: pdf Electronic Code Of Federal Regulations Signature requirements bin/text idx?c=ecfr&rgn=div8&view=text&node=42: &idno=42 Example of who may sign (not all inclusive list) Legal guardian A relative or other person (manage the patient affairs) A representative of the ambulance provider or supplier Agency representative or institutionthatdidnotthat not furnish the services, but furnished care Local Coverage Determination: Transportation Services Ambulance b/medical review/local coverage determinations lcds and articles/ 17 Ambulance: Beneficiary Signatures Beneficiary signature is not required at the time of transport Obtain signature any time prior to submitting the claim to Medicare for payment, if unable to obtain at the time of transport Remember timely filing CMS Ambulance Service Center:

10 Comprehensive Error Rate Testing (CERT) Protect Medicare Trust Fund Measure Correct Claim Process/Payment Assess Evaluate Contractor and Provider 19 Part A CERT Feedback Categories Nov CERT Findings for Claims Data Jan 1, 2011 Dec. 31, % 8% 64% Insufficient Documentation Medical Necessity Incorrect Coding November 2012 CERT Error Feedback article: Part A Educational Tool a/education/comprehensive error rate testing/recent comprehensive error rate testing cert findings part a 2/ 20 10

11 Part A CERT Feedback: February and March 2013 Rural Health Clinic Insufficient Documentation Disagree per SSA 1862(a)(1)(A) IOM Pub 100 4, Ch 9, 20 Method of Medicare Payment for RHC and FQHC Services PUB , Chapter 3, Â (Signature Requirements) Missing: Submitted rural health clinic visit note missing signature of rendering provider. Note is typed with typed initials only. Missing legible, signed and dated clinic note. Initially received clinic note with questionable date unrelated to this claim. Lacks MD signature on clinic note. 21 Part B CERT Feedback Categories Nov CERT Findings for Claims Data Jan 1, 2011 Dec. 31, % Insufficient Documentation 41% 51% Incorrect Coding Medical Necessity November 2012 CERT Error Feedback article: Part B Educational Tool b/education/comprehensive error rate testing cert/ 22 11

12 Part B CERT Feedback: February 2013 Medicine/ Respiratory Services CPT Insufficient Documentation Disagree per SSA 1833(e), 42 CFR Â (d) (2) (iii) (B) and 42 CFR 424.5(a) (6) PUB 100 8, Chap 3 Â Additional Documentation Requests Missing: Both order/intent to order and medical documentation to support necessity of Wheezing Bronchodilation Responsiveness test, Pulmonary Function Test By Gas and Carbon Monoxide Membrane Diffuse Capacity Test. PUB Chapter 3 Â Signature Requirements PUB 100 4, Chapter 1 Â 110 Insufficient Documentation The progress note submitted has illegible physician signature and has no legible identification of the individual who provided or documented the service. Pub Chapter 15 Â Definitions: Order 23 Part B CERT Feedback: February 2013 Medicine/ Cardiology CPT Insufficient Documentation Disagree per SSA 833(e) PUB , Chapter 1, Â NCD for Electrographic Services The documentation submitted included physician's signed progress note; the EKG results, including a written interpretation, with illegible initials; and diagnostic lab test results. PUB , Chapter 3, Â Signature Requirements Missing: An attestation or signature log to identify the author of the EKG interpretation. Review Part B CERT Feedback Errors in the direct link below. b/education/comprehensive error rate testing cert/ 24 12

13 CERT Documentation Contractor Correct Submission of CERT Documentation Submit CERT medical record request bar coded page as the top/first page of medical records Submit all documentation pages for each specific medical record; ensure that requested medical records are complete Regarding recoupment inquiries, providers should contact the Provider Contact Center at 1 (877) The CERT Documentation Contractor does not manage provider recoupment questions Recent CERT Article: Comprehensive Error Rate Testing (CERT): Submitting CERT Documentation error rate testing cert submitting cert documentation/ 25 Comprehensive Error Rate Testing Submitting CERT Medical Record Documentation Respond to Additional Documentation Request (ADR) timely Submit appropriate documentation Including, but not limited: Progress note(s) to match the DOS billed Lab results Operative reports Diagnostic tests Physician orders Legible identifier for services provided/ordered CERT will accept late documentation Appeal unfavorable decisions with additional supporting documentation Appeals Process: b/claims 2/appeals 2 2/ 26 13

14 Help Prevent Errors Medical Review and CERT Develop compliance guidelines / conduct self audits OIG Compliance Programs Index: guidance/index.asp Physicians: Accurate documentation, supports reasonable and medically necessary services / CMS signature requirements Ensure documentation of physician s verified order/plan or documented intent to order diagnostic services Include procedure reports with results Legible handwriting Correct coding Timely submission of requested medical records 27 News & Reminders 28 14

15 Medical Record Documentation MLN Matters Number: SE1237 Importance of Preparing/Maintaining Legible Medical Records General Principles of Medical Record Documentation Be Aware Medical records should be complete and legible; and Medical records should include the legible identity of the provider and the date of service Amendments, Corrections and Delayed Entries in Medical Documentation Documents containing amendments, corrections, or delayed entries must employ acceptable recordkeeping principles Medicare Signature Requirements For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature MLN Matters Number: SE1237 Importance of Preparing/Maintaining Legible Medical Records and Education/Medicare Learning Network MLN/MLNMattersArticles/Downloads/SE1237.pdf 29 Medical Record Documentation Change Request 8033: Progress Notes and Forms Effective: , Implementation: Defines Progress Notes Progress Note Template Licensed/Certified Medical Professional (LCMP) CMS encourages If template is used, select template that allows full and complete collection of information to demonstrate that applicable coverage and coding criteria are met Program Integrity Manual Pub : Chapter 3, Section Progress Notes and Forms Documentation: and Guidance/Guidance/Transmittals/Downloads/R455PI.pdf 30 15

16 Medical Record Documentation Change Request 8105: Amendments, Corrections and Delayed Entries Effective: Recordkeeping eep Principles: cpes Clearly and permanently identify any amendment, correction or delayed entry Clearly indicate the date and author of any amendment, correction or delayed entry No deletion; clearly identify all original content Paper Medical Records Single line strike through (sign and date) Electronic Health Records Distinctly identify changes Date and sign Program Integrity Manual Pub : Chapter 3, Section Amendments, Corrections and Delayed Entries in Medical Documentation: and Guidance/Guidance/Transmittals/downloads/R442PI.pdf 31 Medical Record Documentation Change Request 8205: Minor PIM Changes Chapter 1 Effective Date: Statutory authority Provider self audits The Office of Inspector General (OIG) Compliance Program Guidelines Guidance on establishing compliance program guidance/index.asp Program Integrity Manual Pub : Chapter 1, Section 1.3.9: and Guidance/Guidance/Transmittals/Downloads/R454PI.pdf 32 16

17 Take Our Survey 33 Additional Resources CMS Home Page Web Site: Cahaba GBA Home Page: Cahaba GBA Evaluation and Management Services Information Center b/education/evaluation and management services information center/ Electronic Submission of Medical Records (esmd): Providers have the option to submit medical records electronically; visit CMS Electronic Submission of Medical Documentation (esmd) web page for details: Statistics Data and Systems/Computer Data and Systems/ESMD/index.html 34 17

18 Questions Provider Contact Center Alabama, Georgia and Tennessee Providers: Thanks for Your Attendance! Please complete the electronic evaluation at the conclusion of the webinar OR Submit your evaluation by using the following link below: t h b / b ib / 36 18