Physician Signature Requirements
by John Verhovshek, MA, CPC
The Centers for Medicare & Medicaid Services (CMS) requires that medical services provided or ordered be authenticated by the author’s handwritten or electronic signature. An electronic signature usually contains a date and timestamp, and a printed statement such as “electronically signed by” or “verified/reviewed by,” followed by the practitioner’s name and a professional designation. Stamped signatures are not acceptable, and neither are indications that a document has been, “signed but not read.”
CMS allows minor exceptions to the above rules, as outlined in CMS Pub 100-08 (Medicare Program Integrity), section 18.104.22.168 (Signature Requirements):
- “Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.”
- “Orders for some clinical diagnostic tests are not required to be signed…. if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.
- “CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.”
CMS instructs its payers to disregard orders without a proper signature. In other words, failure to sign the order may mean that the service may not be paid, and would be susceptible to audit findings and takebacks if the claim were paid.
Illegible signatures aren’t a deal breaker, but they require special attention. CMS instructs its payers to “consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry.”
A signature log will consist of the physician’s printed name, full signature, and initials that appear on the document. The physicians can also list his/her credentials for further proof and validation. A signature log might be included on the same page where the initials or illegible signature appear, or might be a separate document.
Providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process. Generally, 24-72 hours is the typical turnaround time for the provider transcription process. Instead providers may employ the signature authentication process.
Per CMS Pub 100-08, section 22.214.171.124, “Medicare does not accept retroactive orders. If the provider’s signature is missing from the medical record, submit an attestation statement from the author of the medical record.” Should a provider choose to submit an attestation statement, CMS recommends the following format:
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.
Medicare Finalizes SNF 2016 Payment Changes
The Centers for Medicare & Medicaid Services (CMS) released a final rule for 2016 skilled nursing facility (SNF) payments, which follows the shift of rates to be based on value and quality of care, rather than volume. According to CMS’ July 30, 2015 Fact Sheet, highlights of the final rule (CMS-1622-F) are:
CMS projects that aggregate payments in FY 2016 to SNFs will increase by $430 million, or 1.2 percent, from payments in FY 2015. This estimated increase is attributable to a 2.3 percent market basket increase, reduced by a 0.6 percentage point forecast error adjustment and further reduced by 0.5 percentage point, in accordance with the multifactor productivity adjustment required by law.
Starting in 2018 for the SNF Quality Reporting Program (QRP), CMS is finalizing adoption of three measures in the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, issued October 6, 2014:
(1) Skin integrity and changes in skin integrity;
(2) Incidence of major falls; and
(3) Functional status, cognitive function, and changes in function and cognitive function.
IMPACT requires, “the implementation of a quality reporting program for SNFs and standardized data reporting across four post-acute care settings, including home health agencies, inpatient rehabilitation facilities, skilled nursing facilities and long term care hospitals.”
Beginning in 2018, SNFs “that do not satisfactorily report required quality data to CMS under the SNF QRP will have their market basket percentage updates reduced by two percentage points.”
See the Program News and Announcements for details.
Dear John: Psychiatric Medication Management
Have a Coding Quandary? Ask John
Q: Which evaluation and management (E/M) codes should be billed for patients seen in either a free-standing post-acute brain injury rehabilitation facility or a free-standing residential brain injury rehabilitation facility? The physician would be visiting the patient for psychiatric medication management.
A: In years past, CPT® included a code for medication management (90862), but that code is no longer active. CPT® instead includes an add-on code for “pharmacologic management” when performed with psychotherapy services (+90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure)); however, that code doesn’t fit in this case because psychotherapy is not performed.
For the medication management described, the best choice is the standard E/M codes for a new or established patient. In the outpatient setting, the codes are 99201-99215.
The American Psychiatric Association (APA) advises, in its “Frequently Asked Questions: 2013 CPT Coding Changes:”
Question: In my outpatient practice I often see patients for medication management and previously used CPT® code 90862, which was deleted for 2013. What code will I use in place of 90862?
Answer: The typical outpatient 90862 is most similar to E/M code 99213. If the patient you are seeing is stable, and really just needs a prescription refill, code 99212 might be a more appropriate crosswalk. If you have a patient with a very complex situation, you might need to use 99214, a higher level E/M code. The E/M codes have documentation guidelines published by the Centers for Medicare and Medicaid Services (CMS) that explain how to determine which level code to choose. There is a link to this information at http://psychiatry.org/cptcodingchanges.
The APA further advises in “Changes to Psychiatry CPT Codes” that to determine the E/M service level, “The 1997 [E/M documentation] guidelines are the most appropriate ones for psychiatrists to use since they include a single-system psychiatric exam.”
Cuban Healthcare System: A Primary Care Model
The United States could learn from the Cuban healthcare system.
Last December, President Barrack Obama announced that it was time — after 50 years of complex policy and politics — to restore diplomatic and economic ties with Cuba. Whatever the pros and cons of this decision, I believe the two countries have a lot to learn from one another.
In December 2011, I had the pleasure to be part of a team of healthcare administrators who toured Cuba to learn how the Cuban government has established an effective public healthcare system. Based on my observations, the Cuban healthcare system works well for them.
While the United States struggles to provide universal, affordable healthcare for its citizens, our Cuban neighbors have made healthcare a constitutional right. The Cuban healthcare system is not only free for all Cuban citizens, the quality of primary care is equal to or better than the United States and other industrial nations, at a fraction of the cost. For example, Cuba has the same 78-year life expectancy as our country, while spending only 4 percent of the amount the United States spends on healthcare per person, annually.
Fundamentals of Cuban Healthcare
According to “Primary Health Care in Cuba, The Other Revolution,” the development of the Cuban healthcare system is based on three central assumptions:
Health is the responsibility of the state;
Health is a social issue, as well as a biological one; and
Health is a national priority, requiring participation from all sectors of the government and civil society.
The basis for the entire Cuban healthcare system is preventive care and the primary healthcare (PHC) model. Although Cuba has achieved success with its current model, it was not the starting point. Shortly after the 1959 revolution, the government established municipal “polyclinics,” which continue to function as multi-specialty clinics. In the early 1960s, the emphasis was on health screenings, vector control, and other measures to bring infectious disease under control. The PHC model of the community family doctor was introduced in 1984.
The healthcare system is now structured on two levels: level 1 is PHC, and level 2 is secondary healthcare (hospitals).
Primary Healthcare Level 1:
- Family doctor unit
- Polyclinics (includes dental care)
- Specialty institutions
- Mothers’ homes
- Grandparent homes (not a nursing home setting, but senior day care)
- Community mental health clinics
Secondary Healthcare Level 2:
- Inpatient hospital
- Inpatient nursing home care (This is minimal, as the culture focuses on family members remaining in the home.)
With the limited time available to our tour group, we did not have the opportunity to visit any secondary healthcare facilities; however, we did visit all of the PHC Level 1 care units. We found the medical directors, physicians, nurses, and everyone we came in contact with to be welcoming and informative.
We learned that the “family doctor unit” is a single physician with a team of nurses, statisticians, and technical assistants who care for a set number of individuals within their community. Eighty percent of Cuba’s physicians are primary care doctors, with only 20 percent trained as specialists. In the United States, these proportions are reversed.
Better Family Healthcare
and Minimizing Hospital Visits
Most primary care offices are on the first floor of a building, and the physician resides on the upper level with his or her family. Physicians and their teams know their patients well, and often tend to three or four generations of the same family in a single home visit. The average number of patients is approximately 1,000 per physician, compared to approximately 2,500 patients per primary care physician in the United States. The physician in each unit has been trained to care for the entire group assigned to him. This includes home visits, specialty care after consulting with specialists in the polyclinic, office visits, acute illnesses, long term care in the home, and — ultimately — keeping his or her patient population out of the secondary level of care (hospitalization). In short, all care is coordinated through the family doctor unit.
Other Cuban Level 1 Healthcare System Components
Polyclinics are larger, more regional clinics that include multiple specialties, dental, rehab, diagnostic lab, radiology, urgent care, and 24 hour emergency services accessible by everyone in the community. Generally, this is done by consultation request of the family unit doctor. But per Cuban health officials, anyone may enter the polyclinic on his or her own. After consultation, the specialist recommends treatment options to the family unit physician. The family doctor then resumes care, consulting with the specialist to meet the continued needs of the patient.
Specialty institutions are available if further specialty care is needed. For example, if a cardiac patient needs further testing, such as a stress test, the patient is referred to the Cardiovascular Institute for further care. Some testing, due to limited resources within the PHC, must be done at the hospital. This varies from procedure to procedure, and resource availability at the time of need. As we would expect, there are fewer magnetic resonance imaging and computed tomography scanners in all of Cuba than exist in my rural Western Pennsylvania hometown marketplace.
Mothers’ homes are maternity homes for at-risk, pregnant mothers or fetuses, based on limited criteria. Mothers can be admitted at any point during their gestation. This would include the need for bed rest due to possible early labor or hypertensive diabetic status or nutritional deficiencies. Ninety-nine percent of babies are born in the hospital; thus, if the expectant mother is in a rural location, she may reside at the mothers’ home late in her trimester. Evidence of Cuba’s success with this model shows up in its infant mortality rate — at 4.6 percent, one of the lowest in the world, and lower than the U.S. rate of 6.4 percent.
A Grandparent home is not equivalent to a U.S. nursing home. They are adult day care centers where working families can bring the elderly during the day. The senior adults are cared for and fed, and have a chance to mingle with other senior adults from the community.
Elderly care is promoted at the home as part of the Cuban culture. Families are encouraged to care for the grandparents with supervision of the family unit physician team. This team also includes
Community mental health centers care for mentally ill patients and support their families in centers located in the community. The director stressed that, optimally, the whole family is involved in the patient’s care and in supporting their own needs as caretakers. Group sessions with patients and families are held daily at the center. For example, mothers of children with attention deficit disorder (ADD) are able to network and lean on each other for support. Each center is staffed with psychologists, psychiatrists, nurses, technicians, and social workers.
Prevention, Not Profit, Is the Primary Focus
The Cuban healthcare system stresses preventive health. Despite limited resources, Cuba has a record unmatched by any economically disadvantaged nation of dealing with chronic and infectious diseases. These include polio (eradicated 1962), malaria (eradicated 1967), neonatal tetanus (eradicated 1972), diphtheria (eradicated 1979), congenital rubella syndrome (eradicated 1989), post-mumps meningitis (eradicated 1989), measles (eradicated 1993), rubella (eradicated 1995), and tuberculous meningitis (eradicated 1997).
You could argue that it’s easy to accomplish such goals when various elements are implemented or mandated within the community. For example, in Cuba education is free from preschool through graduate level degrees, and they integrate the education and healthcare systems. Children are vaccinated and receive periodic checkups at schools. School lessons include proper hygiene, such as brushing teeth, all the way to learning about contraceptive use. Adults are “required” to check in for a yearly physical.
Cuban physicians have learned to work effectively without the heavy emphasis on technology and pharmaceuticals, commonly relied on in the United States. Although they are proud of their ability to diagnosis and treat underlying problems without automatically reaching for a prescription pad, most Cuban physicians acknowledge the benefit of access to cancer-treating technologies and drugs that are not available, today (even though U.S. law exempted medicine and healthcare supplies from the U.S. embargo of Cuba in 1992).
Because the Cuban system is nonprofit and not reimbursement-based, there is no need to spend resources on coding and billing claims for services rendered. The office “statistician” focus is on quality indicators. Despite the lack of ICD-9 and ICD-10, electronic health records, and other end-user systems, they manage to capture data throughout the entire healthcare system. Because Cubans seldom move more than a few houses or blocks from where they were born, the same physician may treat an individual from the cradle to the grave, and has knowledge and records of all family members. This allows office visits to be interactive discussions, rather than focused on meeting evaluation and management documentation guidelines.
Although the embargo has blocked U.S. products from entering Cuba, it has not stopped the Cuban government from giving humanitarian help to other countries. Cuban doctors were some of the first in the world to step up during the 2014 Ebola breakout in Africa. We learned that Cuba has sent more than 125,000 healthcare professionals to provide care in 154 countries. In fact, Cuba — which is approximately the size of Pennsylvania — has more physicians than all of Africa.
The members of my tour group and I received an open invitation to return to learn more about Cuba’s healthcare success and struggles, along with its culture and people. It was a wonderful learning opportunity, and one that I am happy to share with others. If you have any questions, or would like to learn more, please contact me at
Joette Derricks, MPA, CMPE, CPC, CHC, CSSGB, has 35 years of healthcare finance, operations, and compliance experience. A national speaker and author, her unique style is to bridge the regulatory requirements with the practical realities of day-to-day operations. Derricks has provided numerous expert reports and testimony regarding Medicare, Medicaid, and third-party payer regulations with an emphasis on coding, billing, and reimbursement rules. She serves as the vice president, regulatory affairs at Anesthesia Business Consultants, and is a member of the Ann Arbor, Mich., local chapter.
Learning About the Codes and the Bees
Nature can sometimes be the best coding training.
I recently took up beekeeping. It took years of planning and studying, followed by postponement after postponement born of doubt, fear, and ignorance. There were many issues to consider:
- What were the legal implications, and would the neighbors mind?
- Would a hive attract skunks?
- Would the bees sting us or our pets?
- How would they affect our other activities?
Delay after delay happened as we fretted, imagining the worst.
At the last practical deadline for establishing a new hive this spring, I drove home with a shoebox-sized container full of about as many bees as there are codes in ICD-9-CM, and I nervously dumped them into the hive box. My wife and I welcomed them by planting bee-friendly flowers, feeding them sugar water, and hovering over the hive as we did our first child. The bees survived in spite of us.
The hive’s population has grown to around 70,000 worker bees, or about as many codes as you’d find in ICD-10. They’re pretty self-sufficient, and our regular inspections are becoming fewer and more comfortable as we interact with them. While it’s understandable that we had doubts and delays, our anxiety seems silly now. They are a part of our lives, and someday we may harvest honey. More importantly, the world needs more bees to keep plants pollinated and people fed.
What does this have to do with coding? We often seek metaphors to help us with challenges. For the last decade or so, ICD-10 has consumed a good part of our lives while we prepare to use it for all claims. On-again, off-again, ICD-10 has suffered so many delays some believe it won’t happen. Rumors about it abound, and some challenge its necessity and efficacy.
Like our codes, worker bees are individual in activity and purposeful in union. Each worker returns with a unique tale. She carries pollen specific to a plant, and communicates the site and distance of that plant to her colleagues with impressive accuracy. Her role can be appended by the information she brings back or by the state of the hive itself. The ultimate goal is to preserve the hive through expansion and food production. Each hive hums with energy and shared knowledge.
When accepted as they are rather than feared for what they might be, ICD-10 codes are our worker bees, foraging information that makes up an accurate description of a patient’s illness or injury. Neither ICD-10 codes nor bees bear malice, nor do they cause havoc unless mishandled. ICD-10 codes thrive when surrounded by the blossoms of knowledge and acceptance, like honey bees. We harvest honey from bees in the same way we hope to harvest revenue from the new code set.
ICD-10 will finally be implemented in a couple of months. Like my hive, its novelty soon will be forgotten. ICD-10 will help us care for patients and assure ouremployers’ accurate and timely reimbursement. ICD-10 will be a part of our lives, and we may well reap the harvest. More importantly, the world needs the information ICD-10 allows us to share.
Brad Ericson, MPC, CPC, COSC, is director of publishing at AAPC and a member of the Salt Lake City, Utah, local chapter.