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Signature requirements: Guidelines for authentication of Medicare services

Medicare requires that medical record entries for services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. The method used shall be a hand written or an electronic signature. Stamp signatures are typically not acceptable, but CMS will permit 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. 

Other regulations and the CMS instructions regarding signatures (such as timeliness standards for benefits) take precedence. In cases where the relevant regulation, National Coverage Determination (NCD), Local Coverage Determination (LCD) and CMS manuals have specific signature requirements.

There are some circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and IOM Pub.100-02, Chapter 15, Section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g., a progress note) that he intended the clinical diagnostic test be performed. Documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.

Reviewers apply the following signature requirements

If there are reasons for denial unrelated to signature requirements the reviewer need not proceed to signature authentication. If the criteria in the relevant Medicare policy cannot be met because of a key piece of medical documentation which contains a missing or illegible signature, the reviewer shall proceed to the signature assessment.

Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead may make use of the signature authentication process.

Handwritten signature

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, medical review will consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry. 
  • If the signature is missing from an order, medical review will disregard the order during the review of the claim. 
  • If the signature is missing from any other medical documentation, medical review accepts a signature attestation from the author of the medical record entry.

Electronic signatures

Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. 

Physicians are encouraged to check with their attorneys and malpractice insurers in regard to the use of alternative signature methods since there is a potential for misuse or abuse. 

Signature log

Providers will sometimes include a signature log in the documentation 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. Reviewers may encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials.

  • Reviewers consider all submitted signature logs regardless of the date they were created. 
  • Reviewers file signature logs to minimize the cost of future reviews where the signature log may be needed again. 

Signature attestation statement

Providers will sometimes include in the documentation they submit an attestation statement. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.

Should a provider choose to submit an attestation statement, they may choose to use the following statement:

“I, [print full name of the physician/practitioner], 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, e.g., M.D.] when I treated/diagnosed the above listed 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.”

This format is acceptable, CMS currently neither requires nor instructs providers to use certain forms or format. 

If the provider has been contacted regarding an attestation statement or signature log, they must submit the documentation within 20 calendar days. The 20-day timeframe begins on the date:

  • The contractor makes phone contact with the provider, or
  • Date the request letter is received by the provider

If the biller submits a signature log, attestation statement or other documentation to validate the author identity, the reviewer shall consider the contents of the medical record entry. In cases where the provider submits an attestation, the time frame for completing the review is extended 15 days, allowing 45 days rather than 30 days to complete the review.

Note: Reviewers will not contact the biller when the claim should be denied for reasons unrelated to the signature requirement.

First Coast reviewers will document their contact with the provider and/or other efforts to authenticate the signature.

Signature guidelines 

The guideline below assists reviewers in determining whether to consider the signature requirements met.

If a signature is not dated, the documentation must have enough information to show the date of an order, or the date services were performed. If a dated entry appears immediately above or below an undated entry, medical reviewers may reasonably assume the entry date in question. 

 

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