CMAS Body of Knowledge 02: Medical Audit Process and Methodology

1. Knowledge Recap Signature Guidelines for Medical Review Purposes CMAS Body of Knowledge 02: Medical Audit Process and Methodology www.aamas.org

2. Learning Objectives: • Identify the signature guideline requirements for medical review • Apply the signature guidelines during medical audit activities Reference Sources: • Signature Guidelines for Medical Review Purposes • Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions: Section 3.4.1.1 D – Signature Requirements Ready??? Take the interactive exercises in the next few slides … Enjoy and have fun! www.aamas.org

3. Q1: For medical review purposes, an attestation statement is considered valid if • there is a hand signature of the author • It is dated by the author • It contains the appropriate beneficiary information • it is date stamped by the author • 1 and 2 • 2 and 3 • 1, 2. and 3 • 1, 2, 3, and 4 A B Click on the correct option C D www.aamas.org

4. Sorry… not quite Try again! Go back to Q1 Reference Source  Signature Guidelines for Medical Review Purposes www.aamas.org

5. Opps … one more time Go back to Q1 Reference Source  Signature Guidelines for Medical Review Purposes www.aamas.org

6. Great job … you are correct! Go to Q2 www.aamas.org

7. Sorry .. Keep reading! Go back to Q1 Reference Source  Signature Guidelines for Medical Review Purposes www.aamas.org

8. If signature is missing from an order, reviewers will disregard the order during the review of the claim Providers are allowed to add late signatures to the medical record (beyond the short delay that occurs during the transcription process) Reviewers will not consider attestation statement where there is no associated medical record entry or from someone other than the author of the MR entry in question If the signature is illegible, reviewers shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry Orders for clinical diagnostic tests are required to have an authenticated signature Q2-Q6: Which of these statements is TRUE or FALSE Reference Source  Signature Guidelines for Medical Review Purposes www.aamas.org

9. Yes … you are correct! You are doing just fine! www.aamas.org

10. Are you sure? Think again! Go back to Q2 www.aamas.org

11. Wow – awesome! Move on to next item www.aamas.org

12. Q7-Q10: As a medical auditor, how would you handle the following cases? A: Accept the signature – guidelines met B: Contact billing provider and ask a non-standardized follow up question Q7: Signature is illegible, NOT over a typed/printed name & NOT on letterhead, but the submitted documentation is accompaniedby a signature log, or an attestation statement. Q8: The only information you can find is this statement, “signature on file”. Q9: Initials over a typed or printed name. Q10: Unsigned typed note with provider’s typed name. Example: Marcus Welby, MD Q7 Q8 Q9 Q10 Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions: Section 3.4.1.1 D – Signature Requirements www.aamas.org

13. Right on .. But we’re not done yet! Keep going! www.aamas.org

14. Incorrect… c’mon you can do it! Go back and try again www.aamas.org

15. Congratulations.. Way to go! Thank you – hope you had fun. American Association of Medical Audit Specialists 10200 W 44th Avenue, Suite 304 Wheat Ridge, CO 80033 Phone: 720-881-045 Fax: 303-422-8894 Email: info@aamas.org www.aamas.org www.aamas.org