Last Modified: 8/20/2020
Location: FL, PR, USVI
Business: Part A, Part B
Q: What are the signature requirements for medical documentation? Are there any exceptions? What will happen if I submit a medical record without required authentication?
A. The Centers for Medicare & Medicaid Services (CMS) requires that any Medicare service provided or ordered must be authenticated by the author -- the one who provided or ordered that service. Authentication may be accomplished through the provision of a hand-written or an electronic signature; however, stamp signatures are unacceptable.
In addition, any documentation submitted to substantiate the medical necessity for a service billed to Medicare must clearly identify the patient, date of service, and the provider of the service. The purpose of the authentication (signature) requirement is to ensure that the services rendered have been accurately and appropriately documented, reviewed, and authenticated.
The following methods of authentication have been deemed acceptable by CMS:
• Handwritten signature -- a mark or a sign placed on a medical document to signify knowledge, approval, acceptance, or obligation by the individual who provided or ordered the services specified in the medical entry. Requirements for this form of authentication are dependent upon whether the signature is considered legible or illegible.
• Legible signature -- acceptable forms of presentation:
• Legible full signature
• Legible first initial and last name
• Initials placed above a typed or printed name
• Initials accompanied by a signature log -- lists the typed or printed name of the author associated with initials or an illegible signature. Signature logs may be included on the page where the initials or illegible signature is used, or it may be submitted as a separate document.
• Initials accompanied by an attestation statement -- must be signed and dated by the author of the medical record entry, must be associated with a specific medical entry, and must contain sufficient information to identify the beneficiary.
Note: An unsigned handwritten note may be accepted as authentication when other entries on the same page are in the same handwriting and have been signed.
• Illegible signature -- acceptable forms of presentation:
• Illegible signature placed above a typed or printed name
• Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the individual who signed the entry. For example, the provider’s name could be circled to indicate the identity of the individual who signed the entry.
• Illegible signature accompanied by a signature log -- lists the typed or printed name of the author associated with initials or an illegible signature. Signature logs may be included on the page where the initials or illegible signature is used, or it may be submitted as a separate document.
• Illegible signature accompanied by an attestation statement -- must be signed and dated by the author of the medical record entry, must be associated with a specific medical entry, and must contain sufficient information to identify the beneficiary.
• Electronic signatures -- an electronic sound, symbol, or process attached to or logically associated with an electronic medical record to signify knowledge, approval, acceptance, or obligation by the individual who provided or ordered the services specified in the medical entry.
• Electronic signatures must be authenticated, safeguarded against misuse and modification, and should be easily identifiable as electronic, rather than typewritten, signatures.
• As the individual represented by the electronic signature bears responsibility for the authenticity of the information, physicians are strongly encouraged to check with their attorneys and malpractice insurers regarding the use of alternative signature methods.
The following methods of authentication have been deemed unacceptable by CMS and may result in a Comprehensive Error Rate Testing (CERT) finding:
• Unsigned, typed note with provider’s typed name.
• Unsigned, typed note without provider’s typed name
• Unsigned, handwritten note (only entry on the page)
• Illegible signature that is not placed above a typed or printed name
• Illegible signature that is not identified in a letterhead or addressograph
• Illegible signature that is not accompanied by a signature log or attestation statement
• Stamp signature
• “Signature on file”
If the CERT documentation contractor (CDC) requests an attestation statement or a signature log to authenticate a medical record, the organization that billed the claim must submit the requested statement or log to the CDC within 20 calendar days.
The 20-day timeframe begins when:
• The CDC makes actual phone contact with the provider, or
• The CDC request letter is received by the U.S. post office
• Certification of terminal illness for hospice -- a facsimile of an original written or electronic signature is an acceptable form of authentication for certification of terminal illness for hospice.
• Orders for clinical diagnostic tests -- an unsigned order for a clinical diagnostic test that is accompanied by signed medical documentation that demonstrates the treating physician’s intent for the test to be performed is an acceptable form of authentication for the test.
• Other regulations and CMS instructions regarding signature requirements, such as timeliness standards for particular benefits, take precedence over the guidelines listed above. In cases where the relevant regulation, coverage determination, or CMS manual outlines specific signature requirements (e.g., signatures on plans of care must be signed before those services are rendered), those signature requirements will take precedence.
• Rubber stamp -- use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the 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, the provider is certifying that they have reviewed the document.
Electronic prescribing is the transmission of prescription or prescription-related information through electronic media. Health care professionals can electronically transmit new prescriptions as well as responses to renewal requests directly to a pharmacy through a qualified eRx system, which eliminates the necessity for writing or faxing prescriptions for non-controlled substances.
• e-Prescribing for Part B drugs: Non-controlled substances -- if a provider submits an order for a non-controlled substance through a qualified eRx system, the provider is not required to produce a signed hardcopy as evidence to substantiate the drug order.
• e-Prescribing for Part B drugs: Controlled substances -- the Drug Enforcement Agency (DEA) does not permit the prescribing of controlled substances through e-Prescribing systems; therefore, only a signed (pen and ink) hardcopy of the prescription will be accepted as evidence to substantiate a drug order for controlled substances.
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