Jurisdictions J, M and RRB Specialty MAC Medicare Part B CERT Webinar Series: Radiology Services Q

Published 06/21/2021

The following questions were received and answered during our May 27, 2021, webinar.

Question 1: What was the Medicare Learning Network (MLN) Matters number for the resource used today to support radiology documentation information?

Answer: The MLN number is MM11659 for the MLN Matters article “Special Provisions for Radiology Additional Documentation Requests.” We have updated the Resources widget to include the three MLN products referenced in today’s event.

CMS MLN Resources

Question 2: If there are ask-at-order entry questions appended to a signed order from a provider, is it appropriate to support medical necessity? For example, a CT lung screening is ordered and the patient’s applicable smoking habit, pack, years, and so on, are appended to the order?

Answer: Test reports should address relative clinical issues that can support medical necessity.

Question 3: Which manual and section speak of a requirement where electronic signatures must be noted as digital signatures as referred to on slide 42?

Answer: See the MLN 905364 fact sheet titled “Complying with Medicare Signature Requirements.” The specific wording of digitally signed is not required but some statement that indicates it is an electronic signature is part of the guideline.

Correction: The MLN fact sheet titled “Complying with Medicare Signature Requirements” contains details to assist you in being compliant with Medicare’s signature guidelines. It does not contain an IOM manual and section reference that states electronic signatures must be noted as digital signatures. CMS has not published formal guidelines regarding acceptable electronic signatures. However, most MACs have published examples of acceptable electronic signatures which mirror the guidelines in the American Health Information Management Association (AHIMA) Electronic Signature Model Policy for electronic health records. See the Palmetto GBA article “Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices” article for acceptable electronic signature examples.

In reference to slide 42, the example on the right of this slide is defined as an unacceptable signature because it displays letters and numbers to identify the author. If a provider were to submit a signature that reflects this example, our reviewers would consider this as an unacceptable signature because they would have no way of knowing whose signature is represented by the letters and numbers displayed here in this example. The author’s first and last name would have to be clearly defined within the patient’s medical record to properly identify the authenticating author to meet Medicare’s signature requirements. 

Resources

Question 4: If there is a signed order by the provider, but the ICD-10-CM diagnosis code is unspecified, is it appropriate to use an unsigned telephone note by the provider to support medical necessity? Would this require a signature attestation statement? 

Answer: All orders or documents used as an intent to order should be signed to avoid potential denials. 

Addendum: Orders for clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and the Medicare Benefit Policy Manual, chapter 15, section 80.6, states that if the order for a clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g., a progress note) to support that he/she intended for the clinical diagnostic test to be performed. The documentation used to support the intent for a test to be performed must be authenticated by the author via a handwritten or electronic signature. However, if a signature is missing form a patient’s medical record (excluding orders), a signature attestation statement could be used to support the provider’s missing signature. It is also important to note that Medicare does not accept retroactive orders. So, signatures cannot be later added to a patient’s order or to their medical record.

Resource: Medicare Benefit Policy Manual, Covered Medical and Other Health Services, Chapter 15, Section 80.6 (PDF, 1.55 MB).

Question 5: Since this presentation is geared towards diagnostic services, does it include services defined in the 70000 and 90000 CPT group only and not services for surgical services 10000 to 69999?

Answer: While this presentation is primarily for diagnostic services, there is information included that would also apply to surgical services. 

Question 6: Will the Comprehensive Error Rate Testing (CERT) contractor include a release form with their request for medical records?

Answer: A release will not be included with CERT’s request for medical record. When patients are initially insured by Medicare, they sign a release form then that give Medicare authorization to obtain their medical records at any time.

Question 7: I have the medical records that CERT is requesting, and all of the patient’s information match. However, the spelling of the patient’s name is different. What should I do?

Answer: You should submit the medical records that you have along with a copy of the patient’s Medicare card. If there are any issues, CERT’s quality control department will contact you.

Question 8: What is the event code for this session? 

Answer: The course code for this event, which you can add to your Certificate of Attendance, is JMR 3109050.


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