Signature Requirements: Important things to remember

By: Christina Colegrove RN, BSN – Clinical Consultant

The Medicare Program Integrity Manual requires that services provided/ordered are authenticated by the author.  This can be in the form of a handwritten or electronic signature.  Signature stamps are not acceptable. Please see some other important points related to signatures below.

Handwritten Signatures

  • Illegible signatures: MACs, ZPICs, SMRC, and CERT will consider evidence in a signature log, attestation statement, or other documentation submitted to determine the medical record entry author’s identity
  • Signatures missing from an order: MACs, SMRC, and CERT will disregard the order in the review of the claim.
  • Signature missing from medical documentation: MACs, SMRC, and CERT will accept a signature attestation completed by the author of the medical record entry

 

Signature Log

  • Signature logs list the typed/printed name of the author associated with initials/illegible signature
  • Signature logs can be on the actual page with the author’s initials/illegible signature or on a separate document
  • Although not required, it is recommended that the providers’ credentials be included in the log

 

Signature Attestation Statement

  • Attestations must contain sufficient information which identifies the beneficiary and they must be signed and dated by the author of the medical record entry
  • Noridian and CGS both have Signature Attestation Statement forms which are available for use

Electronic Signatures

  • There should be notation that these signatures were electronically signed
  • Electronic systems have a potential for misuse/abuse with alternate signature methods (i.e. the system/software need to be protected against modification)
  • The PIM encourages providers to check with their attorneys/malpractice insurers regarding the use of alternative signature methods

It is also important to note that Medicare considers a physician’s signature to include credentials and a date to be valid. Make sure that you are reviewing your orders to ensure they are correct prior to submitting your claims.