Important Medicare information for your practice

Physician signatures on medical record
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6698 to clarify how Medicare claim review contractors review claims and medical documentation submitted by providers.  This clarification included an outline of new rules for signatures and added language for e-prescribing.

The previous language in the Program Integrity Manual (PIM) required a "legible identifier" in the form of a handwritten or electronic signature for every service provided or ordered.  CR 6698 updates these requirements to require that every service provided or ordered be "authenticated by the author" by handwritten or electronic signature; stamp signatures are generally unacceptable.

CR 6698 also provides some exceptions to the signature requirement.  First, facsimiles of original written or electronic signatures are acceptable for certifications of terminal illness for hospice.  Second, there are other circumstances for which an order does not need to be signed.  For example, orders for clinical diagnostic tests are not required to be signed, but there must be medical documentation by the treating physician that s/he intended the clinical diagnostic test to be performed. The documentation showing intent must be authenticated by the author with a handwritten or electronic signature.  Finally, other regulations and CMS instructions regarding signatures take precedence.  For example, if the NCD, LCD, and CMS manuals have specific signature requirements, those signature requirements take precedence.  However, if these are silent as to signature requirements, the reviewer should follow the guidelines set forth in CR 6698.

In the event that the NCD, LCD, and CMS manuals are silent on whether the signature be legible or present, the Medicare contractors must apply the specific requirements set forth in CR 6698 in reviewing the signature.  For example, contractors must determine if there are reasons for denial of the claim unrelated to the signature requirements.  If there are, the reviewer does not have to proceed to signature authentication.  In addition, if the signature is illegible, the contractors must consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.  If the signature is missing, then the contractors must disregard the order during the review of the claim.  If the signature is not dated, the reviewer must review to ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed or ordered.

In addition, CR 6698 outlined clarifications for electronic prescribing.  E-prescribing can save time, enhance office and pharmacy productivity, and improve patient safety and quality of care.  Through e-prescribing, healthcare professionals can electronically submit both new prescriptions and responses to requests for renewal to a pharmacy without having to write or fax a prescription.  CR 6698 specified some key points regarding e-prescribing: (1) reviewers will accept as a valid order any Part B drugs, other than controlled substances, ordered through a qualified e-prescribing system (defined as one that meets all requirements set forth in 42 CFR 423.160); (2) e-prescribing is not permitted for the prescription of controlled substances, and as such reviewers will only accept hardcopy pen and ink signatures as evidence of a drug order when reviewing claims for controlled substance drugs; and (3) reviewers must accept as a valid order any drugs incident to DME, other than controlled substances, ordered through a qualified e-prescribing system.


Appeals of claims decisions
Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

The five levels of appeals, listed in order, are:

Appeal level

Time limit for filing request

Where to file an appeal

1. Redetermination

120 days from the initial claim determination

Medicare administrative contractor (MAC)

2. Reconsideration

180 days from the redetermination decision

Qualified independent contractor (QIC)

3. Administrative law judge hearing (ALJ)

60 days from the date of the reconsideration decision
* Monetary threshold for requests made on or after January 1, 2009: $120

Office of Medicare Hearings and Appeals

4. Medicare Appeals Council

60 days from the date of the ALJ decision

Departmental Appeals Board

5. Judicial review

60 days from the date of the Medicare Appeals Council decision
* Monetary threshold for requests made on or after January 1, 2009: $1,220

Federal District Court


Medicare Pre payment medical review.
Medicare prepayment medical review is the evaluation of medical records by Medicare prior to claim payment. Medical review determinations require the reviewer to make a clinical judgment about whether an item or service is covered, and is reasonable and necessary.  In order for this determination to be made, the provider must submit a copy of the medical records to Medicare. Medicare prepayment review delays claim payment until Medicare makes a determination that the billed services are covered and are reasonable and necessary.

Providers are selected for prepayment medical review based on Medicare data analysis, Beneficiary complaints, and being located in cities were Medicare fraud is prevalent such as Miami, Houston, New York.  Other reasons for being selected for pre-payment review include unusual billing patterns such as prescribing the same items or services for a high number of patients, consistently prescribing inappropriate treatments, unexplained increases in volume when compared to historical or peer trends.


Termination of prepayment Medical review.  
CFR § 421.505 states that Medicare providers should be removed from pre payment medical review when the following occurs:


Medicare has the discretion to extend non-random prepayment complex medical review if a provider or supplier stops billing the code under review, shifts billing to another inappropriate code to avoid proper calculation of the error rate, fails to respond to requests for medical records, or engages in any other improper claims or billing-related activity to avoid nonrandom prepayment complex medical review.

Medicare Tracks Provider Inquiries
If you have a question about Medicare coverage or how a particular service is to be billed, who do you call? Many physician practices don’t hesitate to pick up the phone and call their Medicare carrier provider representative for guidance. While this can be an effective way of getting certain kinds of questions answered, practices should be aware that their calls to the carrier are being tracked and can be used by the carrier for a variety of things, including initiating audits. A recent Medicare carrier transmittal, Instructions Related to the CMS Standardized Provider Inquiry Chart for FY 2008, updates instructions to carriers on tracking provider inquiries and increases the level of specificity with which those inquiries are to be tracked. To avoid landing on the carrier’s radar screen with potential compliance or billing concerns, therefore, it is generally advisable, with the assistance of a good Medicare consultant, to make Medicare inquiries only in writing and on an anonymous basis.

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Important Medicare Information for your Practice

Physician signatures on medical record
Appeals of claims decisions
Medicare Pre payment medical review.
Termination of prepayment Medical review.
Medicare Tracks Provider Inquiries

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