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Hospitals Accreditation Hinges on Revisions to the Hospital Interpretive Guidelines

September 22, 2009:

Under Medicare’s conditions of participation (CoP) and conditions of coverage (CfC), criteria for medical record authentication by physicians as well as on-call requirements have been revised. To continue participating in the Medicare and Medicaid programs, health care providers and accredited facilities must comply with these revisions.

The CoPs and CfCs lay the groundwork for CMS’s efforts to improve quality of care and protect the health and safety of beneficiaries. The conditions apply to hospitals, ambulatory surgery centers, skilled nursing facilities, home health agencies, hospices, psychiatric hospitals, rural health clinics, comprehensive outpatient rehabilitation facilities, and other facilities. In addition, physical and occupational therapists in independent practice and outpatient services such as outpatient physical therapy, occupational therapy, and speech pathology services are subject to the conditions of participation.

CMS's Interpretive Guidelines for the Hospital Conditions of Participation are the basis for determining hospital compliance. The Joint Commission is the national accrediting organization for hospitals, nursing facilities, and rehabilitation centers. Major revisions were made to CMS’s Interpretive Guidelines in 2008, including regulations on history and physicals, verbal orders, security of medications, anesthesia, and restraints. In January 2009, the commission announced revisions to the accreditation standards to correspond more closely with the CMS hospital standards. It began surveying hospitals for these revised standards beginning July 1, 2009. Hospitals out of compliance could actually be cited by two different agencies.

CMS recently issued regulatory changes to the Interpretive Guidelines for EMTALA addressing new on-call list requirements and options. The Interpretive Guidelines specify that the on-call list requirements apply to all participating hospitals, not just hospitals with a dedicated emergency department.

The Interpretive Guidelines for the Hospital Conditions of Participation regarding medical record entries (42 CFR §482.24(c)(1)) require all patient medical record entries to be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. Transmittal 47, released on June 5, 2009, revised appendix A, “Interpretive Guidelines for Hospitals” related to medical record entries.

Authentication of medical record entries may include written signatures, initials, computer key, or other code. However, there must be a mechanism to determine that the practitioner did, in fact, authenticate the entry. For example, frequently medical records include a physician entry stating “dictated but not read”; if a physician authenticates an entry that he or she cannot review, either because the dictation has not been transcribed or the entry cannot be viewed electronically, this does not meet the standard. The physician must separately date and time his or her signature, authenticating an entry. For certain electronically generated documents, the requirements would be satisfied if the date and time that the physician reviewed the electronic transcription were automatically printed on the document. For example, when using an electronic order set the practitioner would date, time, and authenticate the last page of the final order that resulted from the electronic ordering or entry process, with the last page also identifying the total number of pages.

Hospitals must establish policies and procedures to ensure that rubber stamps or electronic authorizations are used only by the individuals whose signature they represent and that there is no delegation of stamps or authentication codes to any other individual. Transmittal 47 also notes that Medicare payment policy no longer permits use of rubber stamps, and other payers may also have a policy prohibiting the use of rubber stamps as a means of authenticating the medical records that support a claim for payment. Although using a rubber stamp for signature authentication is not prohibited under the CoPs, their use may result in claim denials.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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