MACs, RACs and CERT are on the alert for unsigned charts

by Julia Kyles, CPC on Oct 27, 2017
We all know the saying about documentation: If it wasn't documented, it wasn't done. But don't forget the other part of that saying: If it was documented, but not legibly signed, it still wasn't done.
Unsigned charts can mean more than denials and overpayment demands. CMS reminded auditors such as Medicare administrative contractors that they should refer repeat offenders to the zone/unified program integrity contractor (ZPIC/UPIC) in an update to the Program Integrity Manual issued Oct. 20:
The contractor shall, if they identify a pattern of missing/illegible signatures, refer the issue to the appropriate ZPIC/UPIC for further development.
The guidance in this section applies to all CMS contract auditors, including recovery audit contractors, comprehensive error rate testing, and supplemental medical review contractors.
In the same update, CMS added language — underlined in the following quote — to make it clear that the clinician responsible for the patient's care must sign it.
For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. For example, if the physician’s authenticated documentation corroborates the nurse’s unsigned note, and the physician was the responsible party per Medicare’s payment policy, medical reviewers would consider signature requirements to have been met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.
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