During a recent Compliance Officers meeting CGS Part B Medical Director, Dr. Earl Berman, was approached with a question about signature timeliness guidelines for electronic medical records. Based on this discussion the Kentucky Medical Association recently published an article referencing CGS’ CMD’s response to a two day signature requirement for electronic medical records. This internal guidance, based on the IOM 100-08 Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions, section 22.214.171.124 Signature RequirementsExternal PDF, has been discussed with internal and external subject matter experts and will be rescinded. It has been determined that providers need a few days to reconcile their records. This reconciliation includes receiving labs, x-ray reports, consultation reports, and other aspects that ensure a completed visit note.
The overarching decision regarding claims review is medical necessity of the visit and documentation to support medical necessity. There are no regulatory timeliness guidelines over and above the IOM reference cited above. However, reason would dictate that 10 working days should be ample time to finalize a visit note and sign/authenticate it. If there is a delay past this reasonable timeframe, an attestation should be submitted with appropriate documentation.
CGS expects providers to complete the documentation, including signatures, at the time of the service in order to maintain an accurate medical record and it is expected that an attestation be used for documentation containing, late, missing, or illegible signatures. Claims submitted on or after 12/12/2016, will be adjudicated according to this change.