June 5, 2009
Comprehensive Error Rate Testing (CERT) Program
Physician Signatures
March 30, 2009 the Centers for Medicare and Medicaid Services (CMS) issued the following Joint Signature Memorandum (JSM) (JSM/TDL-09225, 03-26-09):
Recently the Department of Health and Human Services' Office of Inspector General (OIG) conducted an evaluation of the Comprehensive Error Rate Testing (CERT) Review Contractor. As a result of this OIG review, we have concluded that the provision in the Program Integrity Manual (PIM) that has come to be known as the "clinical review judgment" provision is confusing and contradicts itself in parts.
The language, in part, currently reads:
"While MR staff must follow national coverage determinations and local coverage determinations, they are expected to use their expertise to make clinical judgments when making medical review determinations. They must take into consideration the clinical condition of the beneficiary as indicated by the beneficiary's diagnosis and medical history when making these determinations."
This confusion has created different interpretations of when it is appropriate for Contractor Review Staff to use clinical review judgment. Therefore, CMS will clarify the PIM to be explicit that clinical review judgment may not override statutory, regulatory, ruling, national coverage decision or local coverage decision provisions and that all documentation and policy requirements must be met before clinical review judgments applies. We expect to release this PIM clarification shortly.
This JSM does not change IOM Pub 100-2, Ch 15, sect 80.6 et sub. concerning physician's signatures which reads as follows:
An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
- A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;
- A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
- An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.
The JSM is intended to clarify clinical review judgment. When the contactor or CERT requests an order to show medical necessity for services, including diagnostic tests, one of the following should be provided:
- The office notes where the ordering physician documented which services were to be provided
- The lab requisition signed and dated by the ordering physician
Thus, while the lab request itself does not have to have a signature, there must be a signature in at least one of the two places – either on the office note in which the intent to order the test was documented, or on the requisition or lab order slip.
Keep in mind that additions or corrections to medical records should be documented as follows:
- Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, legibly signed and contain a notation that this is a late entry.
- All entries must be legible to another reader to a degree that a meaningful review can be conducted.
- If the signature is not legible and does not identify the author, a printed version should also be recorded.
- Addition of a missing signature must be treated as a late entry, the correction or addition must be dated, preferably timed, legibly signed and contain a notation that this is a late entry.
Every note stands alone, i.e., the performed services and necessary signatures must be documented at the outset. Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry documenting that the service was rendered and was medically necessary.
