Published in the August 2010 issue of Today’s Hospitalist
HOW MUCH IS YOUR SIGNATURE WORTH? Probably quite a bit, judging by the millions of pens that drug reps have handed out to us over the years. Your scribbles clearly mean dollars to those attractive folks who big pharma sends around to visit.
But how much is your signature worth to your hospital, your hospital medicine program and you personally? The answer is either lots and lots or nothing at all, depending on whether people can read it.
Doctors’ handwriting has long been the butt of jokes. But the recent signature guidelines from the Centers for Medicare and Medicaid Services (CMS) are pretty serious stuff when you consider the amount of cash at stake.
The CMS states that “for medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used must be a handwritten or an electronic signature.” Fair enough. You’re spending the CMS’ money (too much, in Congress’ opinion). It needs to know who’s actually spending it.
Electronic signatures are most straightforward. Dictations signed with a computer interface meet muster. Ditto for computerized physician-order entry and electronic prescribing.
But what about your trusty Bic pen? This is where things get hairy.
According to the CMS, a “handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation.” Sounds lawyerly, but let’s run with it. Basically, your scrawl means that you did something (work), knew about something (such as lab results) or want something (orders for tests or procedures). And you’d like the CMS to pay for it, please.
So where’s the rub? You may have a reproducibly bad signature. The staff at your hospital have come to know your scribble, but what if an outside auditor walks in and starts tearing the place apart? Your signature, if it doesn’t clearly identify you as you, is illegible and thus becomes grounds for non-payment for services.
Health care, even at CMS rates, isn’t cheap. Think of all the progress notes you write and orders you sign on a daily basis. Each illegible signature starts a process of subtraction. An MRI of the head, for example, is worth $710 alone.
Just for fun, we pulled some CMS reimbursement figures for Minnesota (yours will be close but probably a little different). The following chart demonstrates the potential value of a high level follow-up visit, as well as several studies that you commonly order together (the hospitalist’s “shotgun”). If you order everything on the menu ” dyspnea and confusion? “the total tab is $655. Payment, however, may be $0 if Medicare can’t read your signature.
And keep in mind that this is for your worst third-party payer. Your financial exposure could be much greater if better-paying health plans decide to jump on the “legible signature” bandwagon.
If you’re really attached to your illegible scrawl, the CMS does have some elaborate workarounds.
One involves a doctor decoder of sorts called a “signature log,” which contains physicians’ names, titles and signatures, and can identify you as the scribbler. (Signature logs must be updated every year.) In an onsite audit situation, the log could be produced to verify your identity. This, as you can imagine, can result in a lot of work for hospital staff, depending on how many of your signatures need to be authenticated.
Another option that the CMS allows is the use of a written attestation statement. That statement basically says that you were you on the date that the entry in question was made and that you are, in fact, a health care provider. Again, this is a lot of work just to avoid learning how to make a proper signature.
For a while, one of us (Dave) tried to use a pocket stamper to meet the CMS legibility requirement. He would enter his signature, which sort of looks like torsades de pointes, and stamp his name beneath it (See “Before … and after” on page 14.). The stamp also helped him meet a hospital requirement for including a call-back number with chart entries and orders.
But then Sue, bless her, pointed out that according to the CMS signature guidelines, “stamp signatures are unacceptable.” Dave still stamps (it’s a nervous tic by now), but he had to admit defeat.
The only real solution is to print pretty. First and last name. Take your time.
The bottom line
The next time you leave the mark of Zorro (or something even less recognizable) in the medical record or on an order, remember that scrutiny of health care delivery is at an all-time high. Auditors are requesting repayments because of illegible signatures even when everything else about the entry is picture perfect.
So here’s the bottom line: Scribble, scribble, watch your payments shrivel; print, print, you’ll make a mint.
David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.