Medical records - Provider signature - Acceptable and unacceptable format - electronic signature

Signature Requirements

Medicare requires a legible identifier for services provided/ordered. The method used must be handwritten or an electronic signature (stamped signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

Exception: Facsimile of original written or electronic signatures is acceptable for the certifications of terminal illness for hospice.

Providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. Facsimile and hard copies of a physician’s electronic signature must be in the patient’s medical record for the certification of terminal illness for hospice. For example, providers need a system and software products that are protected against modification, etc., and should apply administrative procedures that are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested. Physicians should check with their attorneys and malpractice insurers regarding the use of alternative signature methods.

All state licensure and state practice regulations continue to apply. Where state law is more restrictive than Medicare, the state law standard will apply. The signature requirements described here do not assure compliance with Medicare conditions of participation.

• If Medicare reviewers find reasons for denial unrelated to signature requirements -

* Reviewer need not proceed to signature authentication

• If criteria in relevant Medicare policy cannot be met but for a key piece of medical documentation that contains a missing or illegible signature -

* Reviewer proceeds to signature assessment http://www.cms.gov/manuals/downloads/pim83c03.pdf

If you can’t read it, we can’t read it!

Carefully pull and timely submit all the necessary documentation to support all services! BENEFITS OF REDUCING ERRORS

• Ensures the appropriate reimbursement of the providers’ claims

• Prevents unnecessary denials and the need to request an appeal/redetermination

• Reflects a positive impression of a provider industry by having a low error rate

• May prevent additional medical review of the provider and their industry

• Helps support the solvency of the Medicare program


Acceptable and Unacceptable Documentation Signatures

As a reminder, the treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires the signature be a legible identifier for the provided/ordered services.

The physician’s signature can be in the form of either a handwritten signature or an electronic signature. Stamped signatures (i.e., rubber stamps) are not acceptable signatures.

The following list provides examples of acceptable electronic signatures:

 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.

Examples of acceptable handwritten signatures:

 The handwritten signature must be legible.
 The handwritten signature must clearly identify the provider performing the billed services.



Examples of unacceptable signatures:

 The legible signature is missing from the documentation.
 The signature is illegible.
 The signature cannot be verified as that of the performing provider.
 The signature is typewritten but not authenticated by either a handwritten signature or an electronic signature.
 The provider’s letterhead does not constitute legible identification.
 The provider’s initials do not constitute legible identification.

GENERAL TIPS FOR ALL DOCUMENTATION

• Documentation of each encounter includes:

• Patient’s name and date of service

• Reason for the encounter

• An appropriate history and physical exam including any relevant health risk factors

• Reason, results and review of diagnostic tests and ancillary services

• Patient assessment and a treatment plan, including a discharge plan (when appropriate) 105

• Some service may require physician, hospitals, and nursing homes to work together to obtain signed progress notes, plan of care, discharge summary, etc.

• Never sign an order for home health, hospice, durable medical equipment, or diagnostic tests if you do not have a relationship with the patient and can affirm the services/supplies are medically necessary

– Some orders may require a face-to-face visit with the ordering provider 106

• If the signature requirements are not met:

• Reviewer will conduct review without considering documentation with missing or illegible signature


• This could lead reviewer to determine that medical necessity for services billed have not been substantiated