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Physician MUST Date Signature on Home Health & Hospice Certifications/ Recertification's Effective 1/1/2011


Effective Jan. 1, 2011, all Medicare home health and hospice certifications and re-certifications must be not only signed by the ordering physician, but also must be dated by that physician. During a conference call last week, the Centers for Medicare & Medicaid Services (CMS) advised its contractors of this interpretation of the final rule updating the home health prospective payment system for 2011 that was published in the Nov. 17 Federal Register.


According to CMS, this change will be effective for all claims submitted on or after Jan. 1, 2011. CMS referenced current policy manual citations, new home health regulations, and existing hospice regulations and manual citations as the basis for its authority. However, CMS failed to reference longstanding policy found in the home health plan of care instructions that permits fixing the date of receipt of signed orders in lieu of physicians dating their signatures.


The longstanding policy referenced by CMS is found in the Medicare General Information, Eligibility and Entitlement Manual (Pub. 100-01), Chapter 4, section 30.1, which states: "The attending physician signs and dates the POC/certification prior to the claim being submitted for payment." This manual requirement will be put into regulation at 42CFR 424.22 (D)2: "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," and for re-certifications, "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."


Hospices are referred to policy and regulations for physician dates of their signature in the CMS online manual Medicare General Information, Eligibility and Entitlement Manual (Pub. 100-01), Chapter 4, section 60, which states: "Certification statements must be dated and signed by the physician." And the regulation in the November 17 Federal Register 42CFR 418.22 (b)(5) effective Jan. 1, 2011 states: "All certifications and re-certifications must be signed and dated by the physician(s)."


Earlier this year and prior to publication of this regulation, the National Association for Home Care & Hospice (NAHC) wrote to CMS requesting a policy clarification on the signature dating requirements found in Change Request (CR) 6698. The transmittal repeatedly states that signatures must be dated. In its inquiry to CMS, NAHC explained that there has been a longstanding home health policy whereby, if a physician did not date his/her signature, the home health agency could enter the date of receipt on the form. The language found in the CMS paper-based manual on completing the home health plan of care was referenced:


27. Attending Physician's Signature and Date Signed.--The attending physician signs and dates the plan of care/certification prior to you submitting the claim. Rubber signature stamps are not acceptable. The form may be signed by another physician who is authorized by the attending physician to care for his/her patient in his/her absence. 


Do not predate the orders for the physician, nor write the date in this field. If the physician left it blank, enter the date you received the signed POC under Item 25. Do not enter "N/A." Submit an unsigned copy of the HCFA-485. Retain the signed copy.


Affixing the date of receipt in lieu of a physician's dated signature has been CMS' (then the Health Care Financing Administration's, or HCFA's) policy since the HCFA-485 was approved by the Office of Management and Budget in April 1987. Unfortunately, these plan-of-care instructions were deleted from the online Program Integrity Manual about a year ago and were never replaced. However, in response to NAHC's inquiry, CMS assured NAHC that documentation of the date of receipt of signed certifications by the home health agency remained a valid practice in cases where the physician failed to date the plan of care.


NAHC has learned from providers that physicians fail to date certifications and re-certifications as frequently as 25 percent of the time. Requiring the physician date as the only acceptable documentation will create additional burden and cost both on providers that must resend undated forms and physicians who will need to view forms for a second time in order to determine the date of their signature and affix that date to the forms.


When NAHC learned of CMS' plans to require physicians to date certifications and re-certifications, NAHC again wrote to CMS. In response, CMS reversed it position and responded that "while dating certifications has been a longstanding practice, it was not actually spelled out in the regulations. I'm sure you can appreciate the importance of the physician including the date, as it is how we can determine if the certification/ recertification is timely. Program Integrity limits the use of date stamps."


NAHC will continue to lobby CMS to allow home health and hospice providers to affix the date of receipt as proof of physician signature timing -- just as they have done over the past two decades. Stay tuned to NAHC Report for updates.

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