Palmetto GBA
Close Window [x]
  • Entire Site
  • J1 WPS Transition
  • J1 Part A
  • J1 Part B
  • LA & MS Part A EDI
  • NSC
  • Ohio Part B
  • Part A Intermediary
  • Railroad
  • RHHI
  • SC Part B
  • WV Part B
permaLink
Change Font Appearance Change Font to Serif Change Font to Sans-Serif Decrease Font size Expand Font size
Bookmark E-mail PDF Print Digg It! Tweet FB Like

Ohio Part B Carrier
Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices

CMS guidelines mandate the presence of signatures for 'medical review' purposes. However, records pertaining to any procedures billed to Medicare 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 Medicare claims with dates of service on or after March 1, 2010, processed by or medical record submitted to Palmetto GBA for Medical Review purposes on or after April 16, 2010. 

Signature’s Purpose
Medicare requires that services provided/ordered be authenticated by the author. 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 that services submitted to Medicare 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
  • Electronic: 
    • 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 that the responsibility and authorship related to the signature should be clearly defined in the record.
    • Digital signatures are 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.

Acceptable Electronic 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
  • Digitized 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 
  • ‘Signature Derived from Controlled Access Password’
Acceptable Written Signatures:
  • Legible full signature
  • Legible first initial and last name
  • Illegible signature over a typed or printed name
  • Illegible signature where the letterhead, addressograph or other information on the page indicates the identify of the signator. Example: An illegible signature appears on a prescription. The letterhead of the prescription lists three physicians’ names. One of the names is circled.
  • Illegible signature not over a typed/printed name and not on letterhead, but the submitted documentation is accompanied by: 1) a signature log, or 2) an attestation statement
  • Initials over a typed or printed name
  • Initials not over a typed/printed name but accompanied by: 1) a signature log, or 2) an attestation statement
  • Unsigned handwritten note where other entries on the same page in the same handwriting are signed 
Unacceptable Signatures*:
  • Signature 'stamps' alone in medical records are not 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. 
  • Illegible signature not over a typed/printed name and not on letterhead and the documentation is unaccompanied by: 1) a signature log or 2) an attestation statement
  • Initials not over a typed/printed name unaccompanied by: 1) a signature log or 2) an attestation statement
  • Unsigned typed note with provider’s typed name
  • Unsigned typed note without provider’s typed/printed name
  • Unsigned handwritten note, the only entry on the page
 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'
  • 'Filled By'
  • ‘Electronically signed by agent of provider’
*For the sections listed above, with an asterisk (*), Palmetto GBA will contact the person or organization that submitted the claim(s) and ask him/her to submit an attestation statement must be received in our office within 20 calendar days of the call or the date the written request is received by the post office. In order to be considered valid for Medicare Medical Review purposes, your attestation statement must include the following elements:
  • the printed full name of the physician/practitioner
  • sufficient information to identify the beneficiary
  • date of service
  • signature and date by the author of the medical record entry
Should a provider choose to submit an attestation statement, the following statement may be used:
 
“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.”
 
While the above statement is an acceptable attestation format, at this time, Palmetto GBA is neither requiring nor instructing providers to use a certain form or format.
 
Note: The submitter will not be contacted if the claim is or will be denied for reasons unrelated to the signature requirement. If the signature is missing from an order, Palmetto GBA will disregard the order during the review of the claims and the submitter will not be contacted.
 
Unique Signature Situations:
Situation:
Performed by:
Signature Requirement:
Incident to
 
Ancillary Staff
Must be signed by billing provider
NPP (Non-Physician Practitioner)
May be signed by the NPP or the supervising physician
Split/Shared:
Office/Clinic Setting
NPP and Physician
May be signed by the NPP or the supervising physician
Split/Shared:
Hospital Inpatient/ Outpatient/Emergency Department Setting
NPP and Physician
Must be signed by billing provider
Surgery
Assistant at Surgery
Must be signed by the surgeon and the operative report must reference the surgical assistant
Co-Surgeon
Each co-surgeon must sign his/her operative report
Scribe
Ancillary Staff
The scribe's name must be listed in the medical record and identified as a scribe. The signature of the scribe is not required; however the billing provider must sign.

Electronic Medical Records: Recommendations
The electronic system you select should include a process that verifies the individual signing his/her name has reviewed the contents of the entry and determined it contains what he/she 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 the individual, 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.
 
Resources:

The attached job aid can be viewed and printed from the link below.

 

Return to Top
last updated on 06/16/2010
ver 1.0.5.5