Medical Documentation Signature Requirements

All services provided to beneficiaries are expected to be documented in the medical records at the time they are rendered and signed by the provider/supplier as needed.

For a signature to be valid, the following criteria are used:

  • Services that are provided/ordered must be authenticated by author
  • Signatures shall be handwritten or an electronic signature.
  • Signatures are legible
  • Rubber Stamps for signatures are allowed in accordance with Rehabilitation Act of 1973 in case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, provider/supplier is certifying that he/she has reviewed the document
  • Medical record entries completed by a scribe must be authenticated by treating physician’s/non-physician’s (NPP’s) signature and date

Dated Signature

To comply with conditions of participation and receive accreditation, all signatures must be dated and timed; however, reviewers must be able to determine on which date the service was performed or ordered. If the entry immediately above or below the entry is dated, reviewer may reasonably assume the date of the entry in question.

Missing Signature

Providers should not add late signatures to a medical record, other than those that result from the short delay that occurs during the transcription process. Providers should use the signature attestation process. Medicare does not accept retrospective orders.

If a clinical diagnostic test order does not require a signature, regulations state there must be medical documentation by the treating physician (e.g. a progress note) that he/she intended the clinical diagnostic test be performed. This must also be authenticated by the author via a handwritten or electronic signature.

Illegible Signature

Providers may submit a signature log or attestation to support the identity of the signer. There should be some indication in other documentation to support the identity of the signer.

Signature Log

A signature log is a typed listing of provider names followed by a handwritten signature. A signature log can be used to establish signature legibility as needed throughout the medical record documentation. We encourage providers to include their professional credentials/titles as well on the signature log.

If your facility doesn’t have a signature log currently in place, all submitted signature logs regardless of the date they were created will be accepted. While the creation of the log may be a time consuming process, the end result will be that claims with illegible signatures will be processed more quickly than those that do not have a signature log.

Signature Attestation

It is acceptable to attest your signature. CMS has provided a guide for a signature attestation in Change Request (CR)9225 and in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4   .

Signature Log vs Attestation – Speed of Completion

The Additional Documentation Request (ADR) will request a signature log/attestation for claims selected for review. Carefully review submitted documentation to ensure that orders and services are signed appropriately. Initial ADR submissions that include a signature log or attestation for claims with illegible signatures will expedite claim processing.

Signature for Amendments, Corrections, and Delayed Entries

All services provided to beneficiaries are expected to be documented in the medical records at the time they are rendered. Occasionally certain entries are not properly documented and must be amended, corrected, or entered after rendering the service. Health record documents submitted containing amendments, corrections, or addenda must clearly and permanently be identified as such, clearly indicate the date and author of the entry, and clearly identify all original content without deletion. When correcting a paper medical record, amendments or delayed entries may be initialed and dated if the medical record contains evidence associating the provider’s initials with his/her name. When correcting electronic health records, entries must provide a reliable means to identify the original content, the modified content, and the date and authorship of each modification of the record.

Scribe Services

To reduce the amount of documentation overload, many physicians are looking to Medical Scribe services.

Per CMS Change Request (CR)10076 external-link, Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.

Resources

Last Updated Nov 15, 2018