CMS new guidance… Bans the use of physician signature stamp

by Gloryanne Bryant, RHIA, CCS

Back in May 2008, CMS transmittal 248 stated that CMS would no longer accept medical record documentation with physician-stamped signatures but the focus was on hospice and home health. Then on July 29, 2008, the MedLearn Matters (MLN) SE0829 included all providers and suppliers in the guidance. This is due in part to the fact that CMS has had compliance concerns over the use of signature stamps for some time.

The use of signature stamps has been around for many years in health care. One reason was so that the actual signature could be read, but CMS has made it clear that it will only accept handwritten, electronic signature or facsimiles of original written or electronic signatures from now on. Because it states all providers, there is a wide range of health care settings (hospitals – inpatient and outpatient, physician offices, Skilled Nursing, Rehabilitation, Psych, Home Health and Hospice, etc.) included in this guidance. So start communicating to your clinical and nursing staff, medical staff, and physicians about this change.

In order to validate your organization’s compliance with this new guidance, random audits and checks on documentation where signature stamps have been used in the past will be needed. For the hospital setting, I suggest establishing a team approach to this, and including Case Management/UR, Nursing, and HIM as your validation team. Don’t forget to check outpatient departments, because often the Lab and Radiology areas have signature stamps used on the requisitions they receive. Report your findings and identify areas for improvement. Also, determine whether additional education needs to be provided in your organization or office practice.

To get the message out, be proactive and post signs in key areas, including the dictation areas and the Emergency Department.

You can view this MLN Matters via a google search “MLN Matters SE0829” or www.AISHealth.com  and click on “CMS’s MLN Matters”

References
MLN Matters SE0829, Report of Medicare Compliance 8/11/08 Atlantic Information Services, Inc.