Medical Documentation Signature Requirements - JE Part A
Educational Resources
Medical Documentation Signature Requirements
Signatures are required for medical review for the following purposes:
- To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or Local Coverage Determination (LCD); and
- To resolve authenticity concerns related to legitimacy or falsity of the documentation.
Provider/suppliers are encouraged to review documentation prior to submission to ensure that signature requirements in a statue, regulation, NCD or LCD are met, when applicable, and ensure that signature information is available when authenticity may be of concern.
Electronic Signatures
Your electronic signature:
- Must be authenticated, safeguarded against misuse and modification, and easily identifiable as electronic instead of a typed signature.
- Represents the provider who signed it, meaning the provider themselves, and that individual bears responsibility for its authenticity. We strongly encourage physicians and NPPs to check with their attorneys and malpractice insurers when using electronic signatures as an alternate signature method.
These are a few of the electronic medical review guidelines:
- Systems and software products must include protections against modification, and you should apply administrative safeguards that meet all standards and laws.
- Person’s name on the alternate signature method and the provider accept responsibility for the authenticity of attested information.
Noridian may ask for the electronic signature process for your facilities electronic health record to validate authentication. For additional help refer to the Electronic Order Signature Process Form.
Handwritten Signatures
We consider a signature valid if it’s handwritten and legible. If your signature isn’t legible, the reviewer must confirm it by comparing your signature to a log or attestation statement. A printed signature below the illegible signature in the original record is acceptable.
- We don’t accept stamped signatures unless you have a physical disability and can prove to a CMS contractor you’re unable to sign due to that disability. In this case, we allow rubber stamped signatures.
- We don’t accept scribe signatures, even if a scribe dictates the entry on your behalf. You must sign and date the entry to authenticate the documents and care you provided, ordered, or certified. It’s unnecessary to document who transcribed the entry.
Noridian may request a signature log or attestation when the entirety of the medical record does not identify the author of the medical record entry, to validate authenticity or when signature requirements are not met per statue, regulation, NCD or LCD. A "signature log" is a typed listing of physician and NPP names and a handwritten signature. This is an individual log or a group log. The log shows signature identity throughout the medical record. We encourage, but don’t require, physicians and NPPs to list their credentials in the log.
