Medicare

Signature Requirement Changes for Medical Records

Medicare has issued changes (CR 9332) October 2, 2015, to their Program Integrity Manual regarding signature requirement changes.
The purpose of this Change Request (CR) is to allow contractors to accept initials instead of signatures for amendments or delayed entries in medical record entries, as long as there is evidence in the medical record associating the provider's initials with their name.
 
All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations the MACs, CERT, Recovery Auditors, and ZPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described in section B below. The MACs, CERT, Recovery Auditors, and ZPICs shall NOT consider any entries that do not comply with the principles listed in section B below, even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.
 
Record Keeping Principles
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:
  1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
  2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
  3. Clearly identify all original content, without deletion.
Paper Medical Records
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:
  1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
  2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
  3. Clearly identify all original content, without deletion.
Electronic Health Records (EHR)
Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:
  1. Distinctly identify any amendment, correction or delayed entry, and
  2. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
If the MACs, CERT or Recovery Auditors identify medical documentation with potentially fraudulent entries, the reviewers shall refer the cases to the ZPIC and may consider referring to the RO and State Agency.
 
You may access this Change Request here.