Claims Denials Over Missing MD Signatures May Not Stand Up

Physical therapists should consult their Local Coverage Determination (LCD) for Therapy Services for their state (here is Florida's) as well as the national Medicare Benefit Policy Manual for Physical Therapy as they interpret this legal opinion, posted by The Report for Medicare Compliance.

"Medicare has elevated the importance of physician signatures and certifications, but sometimes its reach exceeds its grasp, lawyers say.

If the lack of a signature or certification is used as a reason to deny payment, providers may have grounds to fight back — especially if Medicare administrative contractors (MACs) or auditors are relying on manual provisions that go beyond the statute or regulations.

For example, physician signatures are not required on every page of office notes, although MACs may argue otherwise, says Minneapolis attorney David Glaser, with Fredrikson & Byron.

In 1995 CMS explicitly said that physicians don’t have to sign every page of office notes, he says. And if physician signatures are missing from any other piece of documentation, MACs and the comprehensive error rate testing (CERT) contractor must accept an attestation from the author of the medical-record entry, according to the Medicare Program Integrity Manual.

A standard CERT letter states that “in order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.”

"Claims are denied all the time for the lack of a signature,” Glaser says. “I am not recommending physicians don’t sign charts because they would be asking for trouble. But if you haven’t signed them don’t let them deny your claims because you can do the attestation.”

One carrier denied a physician’s detailed, two-page evaluation and management note because the physician forgot to sign, but he appealed it and won, Glaser says. It is considered Medicare gospel that physician orders must be signed. After all, that’s what the Program Integrity Manual says.

But Glaser contends that’s not always the case and providers shouldn’t assume they are out of luck if a claim is denied because there’s no signature on an order. For one thing, Medicare regulations obviously set forth specific requirements for each service and they don’t all require signed orders. While home health certifications must be written and signed, independent diagnostic testing facility orders must be written but there is no signature requirement, Glaser says.

And while the Program Integrity Manual insists orders must be signed, it’s a manual — not a regulation, he says.

CMS has made it clear that Program Integrity Manuals  lack the force of law.

In several cases, the government filed briefs arguing that if manuals conflict with governing statutes or regulations, a person relies on them “at his peril.”

Glaser says manuals can set a lower standard of care but not a higher standard of care than the regulations."

Physical therapists, especially busy private practice physical therapists, can sleep easier now knowing that ONE missing signature wont invalidate their entire claim. Medicare appeals are expensive but, in some cases, worth it.