Signature Requirement Q&A - JE Part B

View questions and answers regarding signature requirements.

See CMS Change Request (CR)6698 for signature requirements details.

Q1. Do signature requirements also apply to prescription signatures?
A1. Yes. They follow the same signature requirements.

Q2. Other than the lab tests, is a doctor required to sign every page of the documentation?
A2. All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. Only when it is clear that an individual document extends to multiple pages, and that the entire document is then authenticated, would a signature on a single page suffice for other pages as well.

Q3. After a service has been rendered, what amount of time is acceptable to Medicare for the doctor to sign the notes?
A3. In most cases, Noridian expects that the notes are signed at the time services are rendered. Further delays may require an explanation. See CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Section 3.3.2.5 .

Q4. How often are providers required to complete a signature log?
A4. There is no need to update the signature log unless a new practitioner's signature is needed.

Q5. A physician orders physical therapy and the signature doesn't meet criteria. Is the therapist liable for the physician signature or just the signatures of the therapy provider?
A5. Each provider is responsible for his/her own signature. Without the signed order by the physician, the therapist will not be reimbursed.

Q6. When a signature is illegible, can a stamp be used to supplement the illegible signature?
A6. A rubber stamp that has a "printed" name can be used but the practitioner must sign and date the document. No attestation or signature log is required as the printed name will suffice. Also, CMS permits the use of a rubber stamp for signature if the author has a physical disability and can provide proof to a CMS contractor of his/her inability to sign their signature due to his/her disability. See CMS Change Request (CR)8219 .

Q7. Is time a required component of the physician signature with credentials and date?
A7. Certain services require a time element and, in those instances, are required. All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

Q8. A physician sends a verbal order. Can the receiver of the verbal order write the order for the physician? If so, does the physician need to authenticate the order in the record?
A8. Orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations. The order must be countersigned and dated by the ordering physician within an acceptable timeframe.

Q9. How does a provider know if their electronic software work flow meets the electronic signature qualifications?
A9. A provider should check with his/her technical staff or software vendor to verify software/hardware meets or exceeds industry standards and complies with CMS instruction.

Q10. Where does a provider get the log to verify the signature?
A10. The signature log can be created by your facility. The signature log includes the provider's signature along with a typed or printed name. It's also helpful to include the credentials.

Q11. The signature is typed, "signed by Bob Smith, MD." To be acceptable, is a written signature also required?
A11. To be a valid signature, the typed signature must have a handwritten signature with a date authenticating the signature. Typed or stamped signatures alone are not acceptable.

Q12. A physician did not sign the operative report and, during the appeals process, it was denied for lack of signature. Is it too late to have the provider sign?
A12. An attestation statement may be used, by the provider, to authenticate the documentation. A signature added to the documentation, after the fact, is not acceptable.

Q13. If a physical therapist received a provider's order with an illegible signature, but also received the written Plan of Care (POC) certified by the same provider with his/her typed name, can the POC be used as validation for the order?
A13. Since Medicare cannot accept a typed name, an attestation for the POC as well as the order is necessary. Medicare expects the order, notes, and POC to have signatures authenticated by a completed signature attestation form or signature log.

Q14. To meet Medicare requirement guidelines, is it appropriate for the electronic health records to include "authenticated by" or "reviewed by" or "approved by"?
A14. Yes. Any of those statements are appropriate. When documentation is requested by Medical Review or CERT, be sure the documentation has been signed by the provider before sending the appropriate records. Submit final copies, not preliminary or draft copies, of documentation.

Q15. Do late signatures also apply to orders for immunizations (TDAP, PPD, etc.)? The Registered Nurse (RN) signature is included but still need the provider's signature.
A15. The ordering provider is not required to sign the record entry by the RN, but medical documentation must support the ordering provider is overseeing the patient's care as well as a signed order for the services performed by the RN.

Q16. If a lab requisition form is dated and includes a valid legible provider signature, is that considered a valid order?
A16. Yes. It is considered valid for the signature requirement; however, the test is subject to medical necessity by the provider's intent that the clinical diagnostic test should be performed.

Q17. To clarify clinical lab reports and the signature requirements, should the reports be signed by the ordering provider or the lab director?
A17. The order should be authenticated by the provider via a handwritten or electronic signature.
Note: There are some circumstances for which an order does not need to be signed. As an example, orders for clinical diagnostic lab tests are not required to be signed. The rules in 42 CFR 410 and IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1 , state that if the order for the clinical diagnostic test is unsigned, 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 documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.

Q18. When a Physician's Assistant (PA) is billing under his/her own number, should he/she sign the chart notes or should the supervising physician sign them?
A18. The documentation should be signed by the provider providing the service and billing for it. In an" incident to" scenario, the documentation should be signed by the supervising provider with a reference in the notes as to who performed the service or co-signed.

Q19. What regulation states providers are required to sign their own notes?
A19. See CMS IOM, Publication 100-03, Chapter 3, Section 3.3.2.4.

Q20. What if the physician signs the order or progress note but the signature is illegible?
A20. Providers may submit an attestation form or a signature log to support the identity of the signature. In addition, reviewers will be looking for some indication on the documentation to tie the provider of service to the signature on the notes.

Q21. Can a provider use the signature log to validate initials?
A21. Yes. The purpose of a signature log is to identify the provider of service when the signature is either illegible, partial or using initials. If documentation is requested, the signature log must be sent along with the appropriate notes.

Q22. Can the signature log be faxed or does Medicate require the original signatures?
A22. A copy or fax is acceptable.

Q23. The CMS CR6698 does not require credentials. Is this a denial?
A23. For medical review purposes, the reviewer must determine the identity and credentials (e.g.MD, RN) of the signator. Credentials identify the type of provider performing the service.

Q24. When a locum tenens physician provides services, what are the signature guidelines?
A24. Locum tenens physicians are identified using the Q6 modifier as he/she bills under the physician he/she is substituting for. Identify the locum tenens physician within the records and the signature should be that of the locum tenens physician.

Q25. What is the time frame for physicians to sign medical documentation?
A25. CR6698 states that providers should not add late signatures to medical records, (beyond the short delay that occurs during the transcription process) but instead may make use of the signature authentication process.

Q26. A provider enters notes and includes his/her name and credentials directly into an electronic documentation system. Is this acceptable?
A26. There are many types of electronic programs available for electronic medical health records (EMRs). The requirement for Medicare validation is that we must be able to connect the provider of service to the records or notes. The electronic signature component must be able to be authenticated and confirmed by the provider of service.

Q27. Please expand on when a signature or documentation is considered late and no longer eligible for signing or billing. For example, a signature if that is left off the chart note for a month.
A27. Any delay beyond the short delay that occurs during the transcription process is considered a late signature. CMS does not further define what a short delay is, and each provider should determine that in their facility. If the practitioner's signature is missing from the medical record, submit an attestation statement from the author of the medical record.

Q28. If the physician forgets to put his/her credentials on their handwritten notes, is the provider required to refund Medicare or can an addendum be done?
A28. An attestation statement will suffice.

Q29. "Facility A" receives an order from "Facility B" provider, and there is no time or date. Is it "Facility A's" responsibility to obtain another order that has all the appropriate information?
A29. Yes. Per CFR, 482.24(c)(1) - All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.