Physician Handwritten Signature Documentation Requirements

Documentation errors may lead to payment denial or recoupment. Recent CERT findings show that medical records submitted for review lacked a valid signature. Providers are reminded that handwritten signatures must be legible to support services rendered.

Improper Documentation

  • Physician's certification with signature blacked out and the date is missing. This document cannot be used to support timely certification/recertification.
  • Physician's authenticated progress notes were not included in the medical records to support medical necessity or reason for the services.  
  • Physician's signature highlighted (note, when information is highlighted, the information is not visible when copied).

Corrective Measures

Review the medical records prior to sending to make sure the handwritten signature requirements are met. If the signature is unreadable or indecipherable send the added information with the medical record as follows:

  • Signature with a typed or printed name
  • Signature with the letterhead or other information on the page that includes the physician's full name
  • Signature with no typed or printed name or no letterhead with full name then submitted documentation must include a signature log, or an attestation statement

Source: Internet Only Manual (IOM), Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4 (D)

 

Last Updated Jun 27, 2018