Physian's Signature on 485

Any help I can get on this? I have been accepting 485's with the signature on just one page based on the following Q&A:


From: Palmetto GBA HH Coalition Meeting Call, January 10, 2011
Q. The HH Coalition Q & A’s from 8/23/10 included question 10 (c) in regards to the MD signing only one page of the plan of care rather than all of them. The question is that if the document is labeled page 1 of 3, 2 of 3, and 3 of 3 and the MD signs only one page is that ok. The answer in August stated that the MD’s typed name needed to be on at least one page of the document and it says “…. and the physician signs and dates the last page, this would be acceptable for medical review purposes.” Does this mean that if the 3rd page is the only one signed that is the only thing that is acceptable? We often have them to sign page one only and not the subsequent pages and wanted to clarify if that was acceptable too?

A. It is important for the pages of the plan of care to be clearly numbered if there is more than one page and the physician does not sign each page. If the plan of care is clearly numbered (e.g., 1 of 3), and the physician signs only one page, that would be acceptable for medical review purposes.



This happened to be a concern I discussed with recently. This email is news to me and a bit troubling from an Auditor’s perspective. Here is my take. Although the Palmetto GBA HH Coalition believes a single signature for a multiple page plan of care is acceptable, (only if the document is properly numbered) for “medical review purposes”. It does not state it is acceptable as condition of payment under Medicare requirements. Prudently, it seems the majority of the medical industry sectors, such as ours, are choosing to err on the side of caution and require the need of a signature to appear on each page because of trust and regulation issues.

The Code of Federal Regulations, Requirements for Home Health Services states, as a condition of payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s care plan by providing a physician’s signature located immediately prior to the narrative in the certification or recertification form. If the narrative exists as an addendum (which is what any additional pages (487’s) are labeled as on the top of our pages) on the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum. Keep in mind, that from a legal perspective the physicians are certifying only the page in which the signature is present and that signature serve as the basis for authentication for the form(s).

In brief, it is the Compliance Department’s interpretation with regard to the physician signature on plan of care forms, that a dated “legible” physician’s signature continue to be obtained for each page of the plan of care per Chapter IV of 42 CFR.

Comments

  • Hello Celeste :-)

    It is normally best to utilize the code of federal regulations to benchmark your activities by as they are what the ALJ will used to adjudicate your case.
    Q&A documents are essentially policy and procedure, not legally binding, yet we’ll be influential when explaining yourself to the ALJ.
    With that said the following cannot be construed as legal advice, it is simply a cut and paste of the regulation applicable to the situation at hand.

    I’ve been able to work out a fantastic solution for pre-claims review which will help with all of these nitpick, technical and documentation related denials.
    Have a fantastic weekend, and keep up all the great work.

    § 424.22 Requirements for home health services.
    Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.
    (a) Certification—
    (1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify as follows:
    (i) The individual needs or needed intermittent skilled nursing care, or physical or speech therapy, or (for the period from July through November 30, 1981) occupational therapy. If a patient's underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient's care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum.
    (ii) Home health services were required because the individual was confined to the home except when receiving outpatient services.
    (iii) A plan for furnishing the services has been established and is periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)
    (iv) The services were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. 1
    Footnote(s):
    1 As a condition of Medicare Part A payment for home health services furnished before July 1981, the physician was also required to certify that the services were needed for a condition for which the individual had received inpatient hospital or SNF services.
    (v) The physician responsible for performing the initial certification must document that the face-to-face patient encounter, which is related to the primary reason the patient requires home health services, has occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter, and including an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in § 409.42(a) and (c) of this chapter, respectively. The face-to-face encounter must be performed by the certifying physician himself or herself, by a nurse practitioner, a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in collaboration with the physician in accordance with State law, a certified nurse midwife (as defined in section 1861(gg)of the Act) as authorized by State law, a physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the physician, or, for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in an acute or post-acute facility and who has privileges at the facility. The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled, dated and signed by the certifying physician.
    (A) If the certifying physician does not perform the face-to-face encounter himself or herself, the nonphysician practitioner or the physician who cared for the patient in an acute or post-acute facility performing the face-to-face encounter must communicate the clinical findings of that face-to-face patient encounter to such certifying physician.
    (B) If a face-to-face patient encounter occurred within 90 days of the start of care but is not related to the primary reason the patient requires home health services, or the patient has not seen the certifying physician or allowed nonphysician practitioner within the 90 days prior to the start of the home health episode, the certifying physician or nonphysician practitioner must have a face to face encounter with the patient within 30 days of the start of the home health care.
    (C) The face-to-face patient encounter may occur through telehealth, in compliance with Section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.
    (D) The physician responsible for certifying the patient for home care must document the face-to-face encounter on the certification itself, or as an addendum to the certification (as described in paragraph (a)(1)(v) of this section), that the condition for which the patient was being treated in the face-to-face patient encounter is related to the primary reason the patient requires home health services, and why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services as defined in § 409.42(a) and (c) respectively. The documentation must be clearly titled, dated and signed by the certifying physician.
    (2) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.
    (b) Recertification—
    (1) Timing and signature of recertification. Recertification is required at least every 60 days, preferably at the time the plan is reviewed, and must be signed and dated by the physician who reviews the plan of care. The recertification is required at least every 60 days when there is a—
    (i) Beneficiary elected transfer; or
    (ii) Discharge and return to the same HHA during the 60-day episode.
    (2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient's underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient's care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum.

    Michael McGowan, President
    Opera Care, LLC
    www.operacare.com
    michael@operacare.com












    (c) [Reserved]
    > On Jun 22, 2016, at 1:02 PM, Celeste Ladyman wrote:
    >
    > Any help I can get on this? I have been accepting 485's with the signature on just one page based on the following Q&A:
    >
    >
    > From: Palmetto GBA HH Coalition Meeting Call, January 10, 2011
    > Q. The HH Coalition Q & A’s from 8/23/10 included question 10 (c) in regards to the MD signing only one page of the plan of care rather than all of them. The question is that if the document is labeled page 1 of 3, 2 of 3, and 3 of 3 and the MD signs only one page is that ok. The answer in August stated that the MD’s typed name needed to be on at least one page of the document and it says “…. and the physician signs and dates the last page, this would be acceptable for medical review purposes.” Does this mean that if the 3rd page is the only one signed that is the only thing that is acceptable? We often have them to sign page one only and not the subsequent pages and wanted to clarify if that was acceptable too?
    >
    > A. It is important for the pages of the plan of care to be clearly numbered if there is more than one page and the physician does not sign each page. If the plan of care is clearly numbered (e.g., 1 of 3), and the physician signs only one page, that would be acceptable for medical review purposes.
    >
    >
    >
    > This happened to be a concern I discussed with recently. This email is news to me and a bit troubling from an Auditor’s perspective. Here is my take. Although the Palmetto GBA HH Coalition believes a single signature for a multiple page plan of care is acceptable, (only if the document is properly numbered) for “medical review purposes”. It does not state it is acceptable as condition of payment under Medicare requirements. Prudently, it seems the majority of the medical industry sectors, such as ours, are choosing to err on the side of caution and require the need of a signature to appear on each page because of trust and regulation issues.
    >
    > The Code of Federal Regulations, Requirements for Home Health Services states, as a condition of payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s care plan by providing a physician’s signature located immediately prior to the narrative in the certification or recertification form. If the narrative exists as an addendum (which is what any additional pages (487’s) are labeled as on the top of our pages) on the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must sign immediately following the narrative in the addendum. Keep in mind, that from a legal perspective the physicians are certifying only the page in which the signature is present and that signature serve as the basis for authentication for the form(s).
    >
    > In brief, it is the Compliance Department’s interpretation with regard to the physician signature on plan of care forms, that a dated “legible” physician’s signature continue to be obtained for each page of the plan of care per Chapter IV of 42 CFR.
    >
    > ---
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    Michael McGowan, MBA/HCA
    Senior Consultant/Expert Witness
    Medicare Appeals Development,LLC
    Direct 916-343-1164
    Michael@madappeals.com
    www.madappeals.com
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  • edited May 2017
    So the answer is yes. All pages of the 485 must be signed?
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