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Signature Requirements

In reviewing Medicare claims and associated documentation, MACs are obliged by CMS to verify the date on which a service was ordered and performed; this is defined in the CMS IOM as follows:

H. Signature Dating Requirements

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs/UPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ordered.

NGS has established the following standards for providers to follow in documenting mental health services, including psychotherapy:

  • NGS recognizes the mental health providers’ obligation to submit only those portions of the clinical record that are necessary for the MAC review process; this limitation on record sharing meets the standard of protecting each patient’s privacy.
  • The implementation of electronic medical records across the health care spectrum has included many mental health professionals. NGS is aware of the complexities of documenting the scope of mental health services, often provided by a team of mental health professionals with varied licensures and certifications. There is, however, an expectation that the plan of care for patients receiving psychotherapy services is developed, maintained, reviewed and updated by a qualified provider who is primarily responsible for the patient’s mental health care.
  • The provider’s care plan must be a comprehensive plan for services based on the patient’s individual needs and updated on a regular basis. The care plan must be dated and signed by one of the following provider types: physician, nurse practitioner, clinical nurse specialist, clinical psychologist, clinical social worker or clinical licensed master’s social worker, when the plan is initiated and at each review and/or modification.
  • Services by other mental health providers, working within the mental health team, must be performed within the scope of the care plan’s intent; each of these other services must be dated and signed to indicate the date of the service.
  • The provider’s care plan is a reference for all other providers on the mental health team. NGS recognizes that there may be instances in which the care plan date is subsequent to the date of a related mental health service by a team member; this may be due to electronic record processes or limitations or to the provider’s need for additional time to formulate a care plan after evaluating a complex patient. In these instances, NGS reviewers may approve services dated prior to the actual care plan date and will use clinical judgment in assessing these services as relevant and appropriate to the plan of care.

Posted 7/19/2018

Signature Requirements
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