Physician Signatures Missing on Medical Records: CERT Tip

Published 06/06/2021

Palmetto GBA continues to see a problem regarding the absence of a physician signature on medical records reviewed by the CERT contractor. 

Providers should not add a late signature to the medical record (beyond the short delay that occurs during the transcription process). Medical records must be signed prior to their submission to CERT. In many cases when the signature is lacking from the original medical record submission, the provider then submits an appeal with a copy of the medical record signed after the CERT review. Medicare does not accept retroactive orders. In the event a signature is missing, the record cannot be changed. This documentation is unacceptable and Palmetto GBA will contact the provider asking for an attestation statement.

Signature attestation statements are available for download on the CERT contractors website C3HUB.