Medical Documentation Signature Requirements - JE Part A
Medical Documentation Signature Requirements
The ordering or prescribing physician or Non-Physician Practitioner (NPP) must sign a document indicating their knowledge, approval, acceptance, or obligation to services provided or certified. Keep in mind that signature requirements are applicable to orders and other medical documentation used to support medical necessity of the service provided.
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.
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 to validate a signature if it is illegible. 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.
Unsigned Medical Records
If the medical record, with the exception of an order, is missing your signature, send an attestation statement. Unsigned orders aren’t subject to signature attestation, and the reviewer will disregard them if they are required for reviewed service. If a reviewer requests an attestation statement or a signature log to authenticate a medical record, submit your documentation within 20 calendar days. An attestation will be considered if it’s associated with a medical record and created by the author.
- CMS Fact Sheet Complying with Medicare Signature Requirements
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, section 80.6.1
- CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, section 184.108.40.206
- 42 Code of Federal Registry (CFR) 423.160