Medical Documentation Signature Requirements - JD DME

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 must be authenticated by the author
• Signatures shall be handwritten or an electronic signature.
• Signatures are legible
• 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.

Dated Signature

To be in compliance with conditions of participation and receive accreditation, all signatures need to be dated and timed; however, Medical Review (MR) must be able to determine on which date the service was performed or ordered. If the entry immediately above or below the entry is dated, MR may reasonably assume the date of the entry in question. Specific signature requirements found in NCDs, LCDs or other CMS manuals supersede the instructions in CR9225.

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.

If a clinical diagnostic test order does not require a signature, regulations state there must be medical documentation by the treating physician (e.g. a progress note) that he/she intended the clinical diagnostic test be performed. This must also be authenticated by the author via a handwritten or electronic signature.

Illegible Signature

Providers may submit a signature log or attestation to support the identity of the signer. Contractors will be looking for some indication in other documentation to support the identity of the signer.

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. MR 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, MR 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 a guide for a signature attestation in CR9225 and in the IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5. Noridian has adopted this guide 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. MR 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. When an attestation request is necessary, the time frame for Noridian to complete the review is changed to 45 days rather than 30 days.

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. When providing records, particularly those that have been amended or corrected, it is critical that you provide both the original note and any subsequent amendments or corrections to the original note. 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:

1. Clearly and permanently identify any amendment, correction, or delayed entry as such, and,
2. Clearly indicate the date and author of any amendment, correction, or delayed entry, and,
3. Clearly identify all original content, without deletion.

The above record keeping principles apply to all medical records, whether electronic or handwritten; however, the Program Integrity Manual also specifically addresses amendments, corrections, and delayed entries in EHRs with the following instructions:

Medical record keeping within an EHR deserves special considerations; however, the principles specified above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, SMRC and UPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:

1. Distinctly identify any amendment, correction, or delayed entry; and,
2. 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, Scribes are not providers of items or services. 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. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.

Questions Regarding the Signature Requirements

Questions may be directed to the Provider Contact Center. If your facility is currently under medical review, contact the Medical Review Examiner assigned to your file.

The guidelines below will assist in determining whether the signature requirements have been met.

Signature Example	Signature Requirement Met	Signature Requirement Not Met
Legible full signature	X
Legible first initial and last name	X
Illegible signature over a typed or printed name Example: John Whigg, MD	X
Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the signatory. Example: An illegible signature appears on a prescription. The letterhead of the prescription lists (3) physicians' names. One of the names is circled.	X
Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by a signature log or an attestation statement	X
Illegible signature NOT over a typed/printed name, NOT on letterhead and the documentation is unaccompanied by a signature log or an attestation statement.		X
Initials over a typed or printed name	X
Initials NOT over a typed/printed name but accompanied by a signature log or an attestation statement.	X
Initials NOT over a typed/printed name and unaccompanied by a signature log or an attestation statement.		X
Unsigned typed note with provider's name typed		X
Unsigned typed note without provider's typed/printed name		X
Unsigned typed note, the only entry on the page		X
Unsigned typed note where other entries on the same page in the same handwriting are signed.	X
"Signature on file"		X

Acceptable Electronic Signatures (Examples; Not Limited To)

• 'Approved by' with provider's name
• 'Authorized by' with provider's name
• Chart 'Accepted By' with provider's name
• 'Closed by - with date/time' with provider's name
• 'Completed by' with provider's name
• 'Confirmed by' with provider's name
• 'Data entered by' with provider's name
• Digitalized signature: Handwritten and scanned into computer
• 'Electronically signed by' with provider's name
• 'Electronically verified by' with provider's name
• 'Finalized by' with provider's name
• 'Generated by' followed by a signature and treating physician credentials
• 'Released by' with provider's name
• 'Reviewed by' with provider's name
• 'Sealed by' with provider's name
• 'Seized by' with provider's name
• 'Signed before import by' with provider's name
• 'Signed by' with provider's name
• 'Signed: John Smith, M.D.' with provider's name
• 'This is an electronically verified report by John Smith, M.D.'
• 'Validated by' with provider's name
• 'Verified by' with provider's name

Note: 'Signed but not read' is not acceptable

Resources

• CMS Complying with Medicare Signature Requirements Fact Sheet
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
• CMS Medicare Learning Network (MLN) Matters (MM)6698