A Renewed Focus on Medicare’s Signature Requirements

A common reason for claim denials through the Comprehensive Error Testing (“CERT”) program and the medical review process is a lack of provider signatures on orders and medical documentation. Medicare requires that services provided and/or ordered be authenticated by the author. The method of authentication must be a handwritten or electronic signature. Stamped signatures are not acceptable. According to the Centers for Medicare and Medicaid Services (“CMS”), “a handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance or obligation.” An electronic signature validates an electronic medical record in the same way a handwritten signature validates a written medical record. CMS delineates the obligations of the Medicare Administrative Contractor (“MAC”), Zone Protection Integrity Contractor (“ZPIC”) and the CERT program, under the following three situations:

Illegible Signature – MACs, ZPICs, and CERT must consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
Signature Missing from Order – MACs and CERT must disregard the order during review of the claim (e.g., the reviewer will proceed as if the order was not received).
Signature Missing from Any Other Medical Documentation – MACs and CERT must accept a signature attestation form from the author of the medical entry. This does not apply to signatures missing from orders.

In cases in which providers include an attestation statement, the attestation statement will be valid so long as it is (a) signed and dated by the author of the medical record entry; and (b) it contains sufficient information to identify the beneficiary. CMS has provided a sample attestation statement that may (but is not required) be used.

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.

MACs and CERT will not consider attestation statements that lack the medical record entry. Moreover, reviewers are not permitted to consider attestation statements from someone other than the author of the medical record entry in question. Therefore, it is impermissible for a member of the provider’s group to sign for another member’s medical record entries or attestation statements. Notably, reviewers are required to consider all attestation statements regardless of the date on which the statement was created.

CMS provided the following instances in which a the signature requirement had been met:

Legible full signature
Legible first initial and last name
Illegible signature above a typed or printed name
Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signatory (e.g., An illegible signature appears on a prescription, but the letterhead of the prescription indicates three physicians’ names, one of which is circled)
Illegible signature not above a typed/printed name and not on a letterhead, but the submitted documentation is accompanied by a signature log or an attestation statement
Initials above a typed or printed name
Initials not over a typed or printed name, but accompanied by a signature log or an attestation statement

CMS also provided a number of exceptions to the signature requirement rule; the following are excepted:

Faxes of original or electronic signatures for the certification of terminal illness for hospice;
Instances in which an order does not need to be signed (e.g., orders for some clinical diagnostic tests in which the treating physician has documentation showing that s/he intended the clinical diagnostic test to be performed); and
Instances in which other regulations and CMS instructions regarding conditions of payment in connection with signatures take precedence.

In sum, providers should keep the following points in mind to ensure compliance with the signature requirement:

The best practice is to ensure that all record are authenticated at the time of services or shortly thereafter.
Medicare only accepts handwritten or electronic signatures; it does not accept stamped signatures.
Attestation statements may be submitted for illegible signatures; however, they may not be submitted for unsigned orders.
Nobody can sign for the physician.
Physician offices should have a protocol in place to have physicians sign their records within a reasonable time. Wisconsin Physician Service (“WPS”)–the Part B MAC for Illinois, Michigan, Minnesota and Wisconsin–suggests that a “reasonable time” is 48 to 72 hours after the encounter. Signatures must be obtained prior the submitting the claim to Medicare.
When dictating notes, the transcribed note must indicate the physician’s signature–either handwritten or electronic. WPS provides, “it is not sufficient that the provider is designated as dictating the note or his/her name is present in the record.”

More details on CMS’ signature requirement can be found in Section 3.3.2.4 of the Medicare Program Integrity Manual.

For more information on compliance, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510 or (212) 734-0128 or visit the HLP website.