Medical Documentation Signature Requirements - JA DME
Educational Resources
Medical Documentation Signature Requirements
CMS provides signature requirements guidance via CMS Change Request (CR)9225, CR9332, CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4.
In order for a signature to be valid, the following criteria are used:
- Services that are provided/ordered should be authenticated by the author
- Signatures may be handwritten or an electronic signature.
- Signatures are legible
- Stamped signatures are not typically acceptable
- Rubber Stamps for signatures are allowed 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 he/she has reviewed the document.
- Medical record entries completed by a scribe must be authenticated by the treating physician's/non-physician's (NPP's) signature and date.
- Signatures are required upon medical review for two distinct 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
Missing Signature
Providers should not add late signatures to the medical record, other than those that result from the short delay that occurs during the transcription process. Providers should use the signature attestation process. Medicare does not accept retrospective orders.
Illegible Signature
If the signature requirement is not met because the signature is illegible, the signature log process may be used to try and resolve the issue.
Signature Log
A signature log is a typed listing of provider names followed by a handwritten signature. A signature log can be used to establish signature legibility as needed throughout the medical record documentation. Noridian encourages providers to include their professional credentials/titles as well on the signature log.
If your facility doesn't have a signature log currently in place, Noridian will accept all submitted signature logs regardless of the date they were created. While the creation of the log may be a time consuming process, the end result will be that claims with illegible signatures will be processed more quickly than those that do not have a signature log.
Signature Attestation
It is acceptable to attest your signature. CMS has provided guidance for signature attestations in the IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5. Noridian has adopted this guidance and formatted it to this interactive Signature Attestation Statement form. The attestation must be signed and dated by the author of the medical record entry and contain sufficient information to identify the beneficiary.
Signature Log vs Attestation - Speed of Completion
The Additional Documentation Request (ADR) will request a signature log/attestation for claims selected for medical review. Medical review encourages all providers to carefully review all documentation that is submitted for an ADR to ensure that all orders and services are signed appropriately. Initial ADR submissions that include a signature log or attestation for claims with illegible signatures will expedite claim processing.
Signature for Amendments, Corrections, and Delayed Entries
All services provided to beneficiaries are expected to be documented in the medical records at the time they are rendered. Occasionally certain entries are not properly documented and will need to be amended, corrected, or entered after rendering the service. For reference, the Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Section 3.3.2.5 provides the following guidance on amendments, corrections, and delayed entries:
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, SMRC and UPICs containing amendments, corrections or addenda must:
- Clearly and permanently identify any amendment, correction, or delayed entry as such, and,
- Clearly indicate the date and author of any amendment, correction, or delayed entry, and,
- Clearly identify all original content, without deletion.
Records sourced from electronic systems containing amendments, corrections or delayed entries must:
- Distinctly identify any amendment, correction, or delayed entry; and,
- Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record
Scribe Services
To reduce the amount of documentation overload, many physicians are looking to Medical Scribe services.
Per CMS Change Request (CR)10076, when a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician's/non-physician practitioner's (NPP's) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided.
Questions Regarding the Signature Requirements
Questions may be directed to the Supplier Contact Center. If your facility is currently under medical review, contact the Medical Review Examiner assigned to your file.
