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These guidelines affect physicians, nonphysician practitioners, and suppliers submitting claims to Medicare fiscal intermediaries (FI), Part A/B Medicare administrative contractors (MAC), carriers, Recovery Audit Contractors (RAC), regional home health intermediaries, and durable medical equipment (DME) MACs for services provided to Medicare beneficiaries, according to Med Learn Matters article 6698.Note exceptions to signature guidelines Prior language from the Program Integrity Manual stipulated that a legible identifier was required from the ordering provider, either in handwritten or electronic signature form, for every service provided or ordered.While the physician’s signature on a requisition is one way of documenting that he or she ordered the service, it is not the only permissible way of documenting that the physician ordered the service.For example, the physician may document in the medical record that he or she ordered specific services.The prescription letterhead may list three physicians along the top, with one of the names circled. However, if a physician provides an illegible signature, but it does not appear over a typed/printed name and he or she does not submit it with a signature log or an attestations statement, this would not satisfy physician signature requirements. Providers using an electronic system must understand the propensity for misuse or abuse with the availability of alternate signature methods. Reviewers will consider all submitted signature logs regardless of creation date. Green rounds on patient A in the hospital after surgery. Green generates a progress note subsequent to his progress note from the day before on patient A. Green signs with an illegible signature in addition to several initialed dates of service.
The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information to which they are attesting. White is a Fellow at Century Hospital and is rounding with his attending, Dr. To view a sample signature log, access the American Academy of Family Physicians website. To be valid for Medicare medical review purposes, the author of the medical record entry must sign and date the attestation statement, which must contain the appropriate beneficiary information.
What they want is a complete and valid order in place to execute the service.
There also may be some implications from state licensure and/or the Joint Commission for doing it differently.
CMS Med Learn Answer: It is not acceptable for the laboratory to perform any testing without a physician's order or to use a patient's history as the reason for testing.
Laboratory tests can only be performed when there is a written request from an "authorized person," a licensed health professional performing within the scope of his or her state license.