What are the Signature Requirements of Medicare for the Medical Record?

Signature Requirements

•          • Acceptable methods for handwritten signatures are:
•                1. A legible full signature
•                2. A legible first initial and last name
•                3. An illegible signature accompanied by signature log or attestation statement
•                4. Initials over a printed or typed name 
•                5. Electronic signature
•          • Unacceptable signature methods are as follows:
•                1. Rubber stamp signatures, except for clinical diagnostic tests when a treating physician who authenticates medical documentation by handwritten or electronic signature, indicates that he or she intended the clinical diagnostic test be performed
•                2. Illegible signatures with no additional documentation to identify the signature
•                3. Initials with no additional documentation identifying them
•                4. An unsigned note
•                5. A note with the statement “signature on file”

Documentation Signature Requirements

•          • The treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires that 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. 
•          Handwritten Signatures:
•          A handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation. If the signature is illegible, the contractor shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
•          Signature Log:
•          Providers will sometimes include a signature log that lists the typed or printed name of the author associated with initials or an illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document.
•          Attestation Statement:
•          For an attestation statement to be considered valid for Medicare medical review purposes, the statement must be signed and dated by the author of the medical record entry and contain sufficient information to identify the beneficiary.

Who is Liable if the Signature is Not Found on the Medical Record?

Every entry in the medical record must be authenticated by the author – an entry should not be made or signed by someone other than the author. This includes all types of entries such as narrative/progress notes, assessments, flowsheets, orders, etc. whether in paper or electronic format.

Repercussions if Signature is Not Found on the Medical Record

•          • From an auditor’s viewpoint, if it’s not documented, it didn’t happen. Medicare CERT (Comprehensive Error Rate Testing) audits have identified insufficient documentation errors as including the following:
•                1. Incomplete progress notes (e.g., unsigned, undated, insufficient detail, etc.)
•                2. Unauthenticated medical records – no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that document the process for electronic signatures
•                3. No documentation of intent to order services and procedures – incomplete or missing signed order or progress note describing intent for services to be provided

What Happens When the Doctor/Provider Leaves the Practice Before the Record is Signed?

•          • To properly submit a claim for reimbursement, the patient’s medical record encounter must be “closed” and include a valid physician signature.
•                1. Obtain Attestation from the Departed Physician
•                The organization should attempt to have the departed physician attest to the medical record(s). The departed physician’s attestation will stand in place of a physical signature. The attestation should be dated and signed by the departed physician, and the document should contain sufficient information to identify the patient. The departed physician will need to include accurate, true, and complete information regarding the treatment or diagnosis of the patient.
•                2. Another Physician Should Appropriately Close the Encounter
•                If the departed physician is not willing to attest to the medical record(s), another physician in the organization may access the medical record and take the appropriate steps to close the medical record.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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