Everyone knows that medical records must be signed to be valid. Let’s review Medicare’s specific requirements.
Q. Does Medicare look at provider signatures during an audit?
A. Absolutely. Medicare auditors, including your own Medicare Administrative Contractor, zone program integrity, supplemental medical review, comprehensive error rating testing contractors, and recovery audit contractors review claims and associated chart documentation to detect improper payments. Signature requirements are part of these reviews.
Q. What are Medicare’s signature requirements?
A. CMS Transmittal 327, dated March 16, 2010, updated the Program Integrity Manual §3.4.1.1 for signature requirements. It states: “For medical review purposes, Medicare requires that services provided/ordered be authenticated by the persons responsible for the beneficiary in accordance with Medicare’s policies.” That authentication is achieved by a handwritten or an electronic signature — but not by stamped signatures.
The CMS transmittal encourages physicians to check with their attorneys and malpractice insurers concerning the use of alternative signature methods, including electronic signatures. The primary concern is the potential for misuse or abuse. Systems must be protected against the ability to forge, falsify, or “modify” a signature. The responsibility for authenticity of the electronic signature remains with the provider.
Q. What does Medicare consider an acceptable signature?
A. Medicare offers a number of acceptable signature options:
- Legible full signature
- Legible first initial and last name
- Initials over a typed or printed name
- Illegible signature over a typed or printed name
- Illegible signature where other information on the page indicates the identity of the signatory (eg, letterhead with providers’ names printed and one is circled)
In addition, acceptable alternatives include the following:
- A signature log
- An attestation statement per chart entry
- Unsigned note where other entries on the same page in the same handwriting are signed
Sample Signature Attestation Statement
Beneficiary Name: _________________________
HIC# ____________________________________
I, [print full name of the physician], 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, eg, MD] when I treated/diagnosed the above identified 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.
Q. What is a signature log?
A. A signature log is a file copy for the practice or group that contains the typed or legibly printed name of each provider together with the associated illegible signature(s) in the chart. Physicians and other providers are encouraged (but not required) to include their credentials in the log (ie, MD, DO, OD, PA).
Q. What is an attestation statement?
A. An attestation statement substantiates that the entry in the medical record was made by the particular provider whose signature is either missing or does not meet signature requirements. The statement must contain adequate information to identify the beneficiary, the date of service, and the full name of the provider. A sample attestation statement is included in Transmittal 327 but CMS does not require a specific format or form. See Figure 1 for a sample statement.
However, it’s important to note a limitation: an attestation statement is not valid for a missing signature on a physician’s order (eg, for a diagnostic test). If an order is not signed, contractor auditors are instructed to proceed as if the order was not received.
Q. Is a signature retroactive?
A. Sometimes. Reviewers have been instructed to consider signature logs without regard to the creation date. However, a late signature in the medical record, presented as though it was concurrent with creation of the record, is not acceptable.
Q. Do I need to confirm the signatures of ancillary staff in the medical record or signature log?
A. No. Reviewers seek to validate that the provider’s mark or sign exists, which signifies approval, acceptance, or obligation of the information in the medical record. For the purposes of claims, signatures of ancillary staff, including registered nurses, licensed practical nurses, or technicians (including certified ophthalmic assistants, certified ophthalmic technicians, and certified ophthalmic medical technologists) are not subject to audit. However, you may wish to identify signatures of these ancillary staff for internal reasons and may include them in the log. RP
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