HCPro, JustCoding Outpatient - 2018 Issue 31 (July)
CMS responds to denials related to physician orders and signatures
July 31st, 2018
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Article Overview
This article explains recent CMS guidance and proposed Medicare policy changes related to physician orders, signatures, attestation options, and documentation validity. It is relevant to coders, compliance staff, auditors, and providers who want to understand how Medicare reviews missing, illegible, or undated documentation and how those issues can affect payment and audit outcomes. The discussion also places these updates in the context of outpatient diagnostic testing, inpatient admissions, and related Medicare manuals and program integrity guidance.
Why This Topic Matters
Documentation defects are a common source of denials and audit findings, so understanding CMS’ current guidance can help organizations review internal policies, reduce avoidable errors, and better prepare records for Medicare review.
Article Sections
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Introduction
Overview of the documentation issues prompting CMS guidance and the Medicare audit context in which they arise.
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CMS guidance on signature requirements
Discussion of CMS’ general guidance on valid signatures, attestation, signature logs, and related documentation expectations.
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Orders for outpatient diagnostic tests
Summary of Medicare guidance addressing orders for outpatient diagnostic testing, including differences across settings and references to Medicare manuals and contractor review.
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Unsigned and illegible documentation
Coverage of CMS clarifications for unsigned, illegible, and undated entries, along with related documentation authentication concepts.
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Orders for inpatient admission
Discussion of CMS’ proposed inpatient admission order changes and the documentation context for inpatient payment review under Medicare Part A.
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Conclusion
Summary of the article’s overall compliance and documentation themes and the practical relevance for providers.
What You Will Learn
- How CMS is addressing documentation denials tied to signatures and orders
- What general types of Medicare guidance apply to authentication of medical records
- How outpatient diagnostic test orders are discussed in Medicare guidance
- What CMS says about unsigned, illegible, and undated documentation
- How inpatient admission order policy changes are being considered in Medicare Part A
Who Should Read This
- Medical coders
- Compliance professionals
- Auditors
- Physicians
- Hospital revenue cycle staff
- Healthcare administrators
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