SIGNATURES: Medicare Guidelines
Revised: 02.18.13
CGS is still seeing an increase in errors due to inadequate provider signatures on documentation submitted for medical review. Documentation must support the medical necessity of the services provided but without the proper signature of the rendering/billing provider, records cannot be validated and services will be denied. The CMS Program Integrity Manual (Pub 100-8, chapter 3, section 3.3.2.4) states: "Medicare requires a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes."
- Handwritten signature must be legible; many records we received cannot be verified to be that of the provider due to illegibility. When a signature is illegible, you may submit a signature log which contains a typed/printed name of the author along with the initials or illegible signature or an attestation may be submitted. Should you choose to submit an attestation statement, you may choose to use the following statement:
“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.”
- An electronic signature is part of an electronic record and must be executed by the person who performs the service. This form of signature must adhere to security standards in the Health Insurance Portability and Accountability Act (HIPAA). In the instance of an electronic signature, the record should state it is in fact an electronic signature, by using a notation similar to one of the following, along with the typed name of person signing record (please note this is not an all inclusive list):
- Electronically signed by
- Electronically verified by
- Reviewed by
- Authenticated by
These forms of signature documentation are not acceptable and will be considered errors upon review (please note this is not an all inclusive list):
- Signed but not read
- Signed before reading
- Dictated by
- Electronically signed and sent without review to avoid delay
- Signature on file
- Provider name typed but not signed
- Digital: An electronic image is an individual's handwritten signature reproduced in its identical form using a pen tablet. (Note; this is an "actual" real time signature done electronically, like the digital sign-out with a credit card transaction) If using the digitized signature method of a written signature that is typically generated by special encrypted software that allows for sole usage, also submit your protocol outlining the guidelines followed by each user.
The legible (signature) identifier requirement applies to documentation for any service performed and submitted to Medicare.
Reference:
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