Dating and signing diagnostic test orders
It is to be unique to the individual, and not reassigned nor reused by someone else.
Furthermore, measures should be in place to protect the 'links' between electronic health information and signatures which prevent unapproved alteration through removal, copying or transfer.
Page 9 of this document describes changes in what is acceptable and not acceptable for documentation to support the medical necessity of services provided.
Impact of the More Stringent Review Criteria The more stringent review criteria for review of claims selected for the November 2009 report resulted in increases in error rates due to: In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment.
(A substantive portion of the E/M visit includes at least one of the three key components (history, exam, or medical decision making.)Must be signed by billing provider.
Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit.
To avoid unnecessary payment denials, rejections or overpayment situations, we strongly urge providers to check with their technical staff or software vendors to verify their current record-keeping and signature processes are in compliance with CMS instructions.