Last Modified: 6/30/2020
Location: FL, PR, USVI
Business: Part A, Part B
Q: What is the most common, avoidable CERT error? How can it be avoided?
One of the most common CERT errors is a missing or illegible signature in the medical record.
The Centers for Medicare & Medicaid Services (CMS) requires that providers of Medicare services comply with the signature legibility requirements outlined in the Medicare Program Integrity Manual, Chapter 3, Section 18.104.22.168
. The CERT contractor is required to assign a CERT error when a provider submits medical documentation with no signature, an illegible signature, initials, an unauthenticated electronic signature, or an unsigned typewritten signature.
Although the enforcement of this CMS requirement has caused a significant increase in CERT errors related to this compliance issue, this particular error can be easily avoided by meeting one of the following criteria:
• Ensure that each medical record submitted for review includes the legible signature of the provider of services
• If the provider’s signature is illegible, include a signature legend/log that clearly identifies the author associated with the illegible signature or initials
• If an electronic signature is used, it must be authenticated, safeguarded to prevent misuse, and should be easily identifiable as an electronic rather than a typewritten signature.
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