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June 2, 2016

Late Signatures
(CMS PUB 100-8, Chapter 3, sec 3.3.2.4)

CGS Medical Review is seeing a large number of documentation being submitted with late signatures. The Medicare Guidelines for late signatures states:

"Providers should NOT add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process."

What providers should know:

  • DO NOT SIGN YOUR DOCUMENTATION LATE - SUBMIT AN ATTESTATION
    • One attestation for each date of service.

Sample Attestation:

I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]__when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability."

Guidelines for Medical Review:

  • If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing (late) or illegible signature. This could lead the reviewer to determine that the medical necessity for the service billed has not been substantiated.

To avoid denials based on signatures the documentation you submit in response to a request should comply with these requirements.

Reference:

CMS Pub 100-08 Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Action, sec 3.3.2.4 Signature Requirements:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdfExternal PDF


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