Every now and then I read about how Medicare has denied payment for certain services due to lack of authentication of medical record entries. That means no physician signature on orders, progress notes, histories and physicals, etc., or the signature is illegible and there is no attestation or signature log to verify the author of the medical record entry.

I often wonder how easy it would be for Medicare to go after that issue alone. Typically, authentication of medical record entries are not the subject of focused reviews, but are identified during audits of other issues. I recently read a publication from CMS regarding CERT reviews for the medical necessity of AICD placements and was very surprised to learn that the vast majority of denials were for missing physicians’ signatures and other issues lumped into record keeping. It doesn’t matter how well the medical necessity was documented of the need for the AICD if the physician didn’t sign his procedure note or his signature was illegible it was an automatic denial. Talk about easy money.

“The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, and this included lack of:

  1. Physician’s signature on the procedure note;
  2. Signature log or attestation for cases in which the physician’s signature was illegible;
  3. Electronic record protocol/policy that documents the process for electronic signatures, if applicable;
  4. Hospital records;
  5. Records for the specified date of service;
  6. Records that support the clinical indication for the procedure; or
  7. Records to support that the beneficiary was enrolled in a clinical study/trial.

In the CERT study, medical necessity errors caused approximately 12 percent of the improper payments.”

Besides internal processes for ensuring appropriate authentication of medical record entries, I think we also have to consider whether our electronic medical records and hybrid (part paper, part electronic) medical records are playing a role in these denials.

What does your medical record look like if you print it out and send it to a reviewer? What does it look like if you send the record electronically? Is it clear to the reviewer that the physician did indeed sign the procedure note? It’s too easy for the payer to deny payment for a such a simple and correctable mistake as a missing physician signature.