September 23, 2013 - Reviewed: 04.07.2022
Signatures
Where does it say documentation must be signed?
Guidelines regarding signature requirements are located in the CMS Medicare Program Integrity Manual (Pub. 100-8), chapter 3, section 3.3.2.4, “Signature Requirements
.” Information is also available in CMS MLN Matters article MM6698, “Signature Requirements for Medical Review Purposes.”
Please note that all services ordered or rendered to Medicare beneficiaries must be signed. While orders for diagnostic tests do not have to be signed, either the order must have a signature or the intent to order the specific test must be clearly documented in the medical record, and that must be signed. One or the other must be signed.
If I inadvertently forget to sign a note, what should I do?
You should not add a late signature to the medical record but instead make use of the signature authentication process. Guidance on this signature attestation process is available in CMS MLN Matters article MM6698, “Signature Requirements for Medical Review Purposes.” A sample attestation statement
is available on the CGS website.
What is considered an acceptable signature?
Signatures may be handwritten or electronically signed. With few exceptions, stamped signatures are not acceptable, as described in the CMS Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4. CMS will permit the use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to a disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.
If the signature is handwritten, it must be legible or have a signature line with a typed and/or printed version of the name of the person signing. If the signature is electronic, the signature must include a phrase similar to "electronically signed by, reviewed by, etc." and may include the date and time of the signature.
Please note that only the person actually performing the service can sign the documentation. A partner or provider covering for another cannot sign the order, record or attestation statement.
What happens if I do not submit an attestation?
If CGS requests an attestation from you and you do not provide one, we will recoup any payment we have issued for the service. If the claim has not yet been paid, CGS will deny the claim.
Section 1833(e) of the Social Security Act
states that we (as a CMS contractor) must have sufficient information to determine the identity of the provider performing the service; the valid signature is the method we use to make this determination. Not submitting a valid signature, or the attestation, upon request is the equivalent of having no documentation, and in these situations, we are obligated to recoup any monies paid. We strongly suggest that all health care providers who submit claims to Medicare develop internal processes to ensure that all documentation in patients’ medical records includes the appropriate signature(s).
For more information, please refer to the CGS website for signature requirements.
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