Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable Practices
While CMS guidelines mandate the presence of signatures specifically for all 'medical review' purposes, modifiers, etc., records pertaining to any procedures billed to Medicare Part B are potentially subject to review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.
The contents of this article are applicable to every Medicare claim processed by or medical record submitted to Palmetto GBA on or after April 28, 2008, (for dates of service on or after September 3, 2007). These instructions do not address CMS documentation requirements for specific situations.
Signature’s Purpose
Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials, e.g., P.A., D.O., or M.D.
The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate the Part B services have been accurately and fully documented, reviewed and authenticated. Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.
Medicare Requirements for Valid Signatures
Acceptable methods of signing records/test orders and findings include:
- Handwritten signatures or initials
- Electronic signatures:
- Digitized signature - an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet
- Electronic signatures usually contain date and timestamps and include printed statements, e.g., 'electronically signed by,' or 'verified/reviewed by,' followed by the practitioner’s name and preferably a professional designation. Note: The responsibility and authorship related to the signature should be clearly defined in the record
- Digital signature - an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage
Note: Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-signature' systems, some of which do not mandate or permit the provider to review an entry before signing. Indications that a document has been, 'Signed but not read' are not acceptable as part of the medical record.
Acceptable Signature Examples
- Chart 'Accepted By' with provider’s name
- 'Electronically signed by' with provider’s name
- 'Verified by' with provider’s name
- 'Reviewed by' with provider’s name
- 'Released by' with provider’s name
- 'Signed by' with provider’s name
- 'Signed before import by' with provider’s name
- 'Signed: John Smith, M.D.' with provider’s name
- Digitalized signature: Handwritten and scanned into the computer
- 'This is an electronically verified report by John Smith, M.D.'
- 'Authenticated by John Smith, M.D'
- 'Authorized by: John Smith, M.D'
- 'Digital Signature: John Smith, M.D'
- 'Confirmed by' with provider’s name
- 'Closed by' with provider’s name
- 'Finalized by' with provider’s name
- 'Electronically approved by' with provider’s name
Unacceptable Signatures
- Signature 'stamps' alone in medical records are no longer recognized as valid authentication for Medicare signature purposes and may result in payment denials by Medicare
- Reports or any records that are dictated and/or transcribed, but do not include valid signatures 'finalizing and approving' the documents are not acceptable for reimbursement purposes. Corresponding claims for these services will be denied.
- See unacceptable signature examples:
- 'Signing physician' when provider's name is typed
Example: Signing physician: ______________________
John Smith, M.D.
- 'Confirmed by' when a provider's name is typed
Example: Confirmed by: ______________________
John Smith, M.D.
- 'Signed by' followed by provider's name typed and the signing line above, but done as part as the transcription.
- 'This document has been electronically signed in the surgery department' with no provider name.
- 'Dictated by' when provider's name is typed
Example: Dictated by: ______________________
John Smith, M.D.
- Signature stamp
- 'Signature On File'
Question: What if I can't get a handwritten or electronic signature because the provider is deceased or has left the practice?
Answer: If the provider is in a group practice, another provider within the group may sign on his/her behalf; however the following information must be provided:
The submitting provider, John W. Smith, M.D., is unable to sign this medical record because he expired on 10/08/08.
or John W. Smith, M.D. relocated to Colorado on 10/08/08 and was unable to sign this medical record.
Unique Signature Situations:
- Incident to: Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. Only the Past, Family, and Social History (PFSH) and Review of Systems (ROS) may be documented by ancillary personnel incident to and incorporated in to the E/M documentation, which must be reviewed and signed by the billing provider.
Services of nonphysician practitioners ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition are also covered as services incident to a physician’s professional services. If the NPP performs an entire service incident-to the physician (office/clinic/home settings only), the medical record may be signed by the NPP or the physician.
- Split/shared services:
- Office setting: When an E/M service in an office setting is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed 'incident to' if the requirements for 'incident to' are met and the patient is an established patient. The service is reported using the physician’s billing number. The physician must sign.
If 'incident to' requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s billing number, and payment will be made at the appropriate physician fee schedule payment. The billing NPP provider must sign.
- Hospital-based setting: When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's number. Payment will be made at the appropriate physician fee schedule rate based on the billing number entered on the claim. The billing provider (physician or NPP) as determined above must sign.
- Assistant at surgery: It is not required that a surgical assistant also sign the operative report in addition to the responsible surgeon when reference is made in the note that identifies the assistant, provided that the report contains an acceptable signature by the responsible surgeon
- Regarding Co-Surgeons: The co-surgeon must follow the signature requirements and provide an acceptable signature
- Scribes: The signature of the scribe is not required. The scribe's name needs to be listed in the medical record and identified as a scribe. The signature requirements for the billing provider still apply.
Electronic Medical Records: Recommendations
The electronic system you select should include a process that verifies the individual signing their name has reviewed the contents of the entry and determined it contains what they intended.
Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic signatures, by whatever method, by anyone other than the designated individual to whom it is assigned. It is to be unique to him/her, and not reassigned nor reused by someone else. Furthermore, measures should be in place to protect the 'links' between electronic health information and signatures which prevent unapproved alteration through removal, copying or transfer.
To avoid unnecessary payment denials, rejections or overpayment situations, we strongly urge providers to check with their technical staff or software vendors to verify their current record-keeping and signature processes are in compliance with CMS instructions. Software/hardware should meet or exceed industry standards to avoid compromising the integrity of documentation and signatures.
For reference and exceptions, please refer to the Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.4.1.1 B and MLN Matters article # MM 5971. They are accessible through the following two links: