February 3, 2023
Reminder: Medicare Guidelines Regarding Orders
MLN905364 – Complying with Medicare Signature Requirements (cms.gov)
Orders communicate the need for a patient to get a test, procedure, or piece of equipment. Sign orders promptly, and in some cases, before starting the service and may be delivered via the following forms of communication:
- A written document signed by the treating physician/practitioner, which 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 signed by the ordering provider on their 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 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
- You or your organization may send a signature log or attestation statement to support the identity of any illegible signatures. 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 review 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
REMEMBER: While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed, and that documentation MUST contain a signature.
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