November 5, 2008

In an October 24, 2008 memo to State Survey Agency Directors, the Director of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification Group clarified signature requirements for standing orders and preprinted order sets and informed hospitals that Medicare will not accept rubber signature stamps as sufficient documentation to support a claim for payment.  These clarifications are effective immediately.

Standing Order Clarification. To eliminate any confusion that may have been caused by prior memoranda, CMS states that while the use of standing orders must be documented as an order in the patient’s medical record, the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care or other patient safety advances. The standing order should be entered into the order entry section of the patient’s record as soon as possible after implementation of the order (much like a verbal order would be entered), with authentication by the practitioner responsible for the care of the patient. In addition, CMS states that all qualified practitioners responsible for the patient’s care and authorized by the hospital in accordance with State law and scope of practice are permitted to issue patient care orders. This may include not only the attending physician, but also hospitalists, intensivists, and residents. Where the authority has been delegated, nurse practitioners and physician assistants may also write orders to the extent recognized by State law.

Preprinted Order Sets. CMS allows the use of hard copy preprinted order sets or equivalent computerized programs that may include a menu of medications or actions from which the qualified practitioner makes selections to be applied to a particular patient. Preprinted order sets should be reviewed and approved by the hospital’s medical staff, and like all orders, must be dated, timed and authenticated promptly by the ordering physician or another practitioner who is responsible for the care of the patient. To reduce the burden on practitioners, CMS is revising prior guidance to require that the practitioner using a preprinted order set must sign, date and time the last page of the orders, with the last page also identifying the total number of pages in the order set. Additionally, the practitioner must sign or initial any other (internal) pages of the order set where selections or changes have been made. The practitioner should sign or initial the top or bottom of the pertinent page(s) and also initial each place in the preprinted order set where changes (e.g., additions, deletions) have been made. It is not necessary to initial every preprinted box that is checked so long as there are no changes made to the option(s) selected.

For pre-established electronic order sets, the same principles would apply, so that the practitioner would date, time and authenticate the final order that resulted form the electronic selection/annotation process, with the exception that pages with internal changes would not need to be initialed or signed if they are part of an integrated single electronic document.

Rubber Stamps. While the Medicare Conditions of Participation and Illinois state law both allow the use of signature stamps when properly controlled, for authentication of medical record entries, Medicare will not accept a rubber stamp signature as sufficient documentation to support a claim for payment. In deciding under what, if any, circumstances rubber signature stamps will be used in their facilities, hospitals should be aware that Medicare claims for payment that use a rubber stamp signature to support the claim will be denied, according to a Medicare spokesperson.

Some hospitals have asked whether a rubber stamp could be used in addition to the ordering practitioner’s actual written signature. CMS instructs hospitals to check with their Fiscal Intermediary before any use of rubber stamps.

To view the CMS Memorandum, click here.

We hope this information is helpful. If you have questions, please contact Barb Haller at bhaller@ihastaff.org or 630.276.5474.