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February 3, 2023 – Updated 09.05.24

Reminder: Medicare Guidelines Regarding Orders

CGS developed this article to address the high Comprehensive Error Rate Testing (CERT) error rate related to orders for laboratory or radiology services (i.e., missing signature or order of intent). The information below explains the importance of submitting this documentation when a Medicare contractor requests it.

To meet Medicare's billing and coverage policy signature requirements, reviewers look for medical documentation that is signed and dated by those responsible for providing care to the Medicare patient. If the medical record entries don't meet the signature requirements, the associated claims may deny.

Signatures are required upon medical review for two distinct purposes:

  • To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and
  • To resolve authenticity concerns related to legitimacy or falsity of the documentation.

Orders communicate the need for a patient to get a test, procedure, or piece of equipment. Please sign orders promptly.

Orders may be delivered via the following forms of communication:

  • A written document signed by the treating physician/practitioner that is hand delivered, mailed, or faxed to the testing facility
  • A telephone call by the treating physician/practitioner or his/her office to the testing facility
  • An electronic mail by the treating physician/practitioner or his/her office to the testing facility

HELPFUL TIPS:

  • 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 AND the ordering provider must sign the document upon his/her next visit to the facility.
  • You can't create missing orders after the fact to backdate a plan of care or other service. If there's no order in the submitted medical record, we'll deny payment.
  • We may accept unsigned orders for clinical diagnostic tests if a signed progress note in the record indicates the practitioner's intent to order the test.
  • You can't add late signatures to orders or medical records (beyond the short delay that happens during the transcription process). We don't accept retroactive orders. If your required signature is missing from the medical record (other than an order), send an attestation statement. We accept a signature attestation for medical documentation, except orders. The attestation must be associated with a medical record and created by the author. Attestations may be considered, regardless of their creation date, unless the regulation or policy indicates the signature must be in place before a given event or date.
  • If you rely on a medical student's documentation, you must review and verify (sign and date) the student's medical record entry.
  • You or your organization may send a signature log or attestation statement to support the identity of any illegible signatures in the original record. A signature log shows signature identity throughout the medical record. We accept a printed signature below the illegible signature in the original record.
  • Documentation must have enough information to show the date you ordered or performed the services. If you dated the entries immediately above and below an undated entry, medical reviewers may reasonably assume the entry date in question.

ELECTRONIC SIGNATURES:

  • Systems and software products must include protections against modification, and you should apply administrative safeguards that meet all standards and laws.
  • The individual's name on the alternate signature method and the provider accept responsibility for the authenticity of attested information.
  • Order Part B medications, other than controlled substances, through a qualified e-prescribing system

NOTE: Stamped signatures are not typically acceptable. CMS permits use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.

REMEMBER: While a physician order does not require a signature, the physician must clearly document his or her intent for the test to be performed in the medical record, and that documentation MUST contain a signature.

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