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To our Referring Providers: Our radiology practices have collaborated to bring this important issue to your attention.
CMS recently published a transmittal that provides specific requirements associated with authenticating orders for tests.
Forms both paper and computer generated with multiple pages must also have the resident name and number on all pages.
Every entry in the medical record must include a complete date – month, day and year and have a time associated with it.
must be signed by the ordering physician or NPP.” This information is being presented to you for your convenience.
Orders that are not authenticated by the author in one of the acceptable formats listed above will be deemed non-reimbursable.
Signature’s Requirements Medicare requires that services provided/ordered be authenticated by the author. The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated.
The signature for each entry must be legible and should include the practitioner’s first and last name. Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.
Stamp signatures are not acceptable.” CMS also requires that orders presented from the treating physician or non-physician practitioner (NPP) be signed (either handwritten or electronic) by that treating physician or NPP.
"For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.
Stamp signatures are not acceptable." "Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process) but instead may make use of the signature authentication process." While this CMS requirement does not govern commercial health plans, Priority Health has made the business decision to adopt the CMS signature requirement across all of its lines of business.
This standard is recognized as a best practice by professional associations such as the American Health Information Management Association (AHIMA) and the American Academy of Family Physicians (AAFP).
The individual who ordered and/or provided services must be clearly identified in the medical records to: Priority Health will permit the use of an attestation form when a signature has been inadvertently omitted.