FAQ-Medicare Signature Guidelines

Medicare Signature FAQ’s

Q: What is required for a valid signature?
A:
  • Services provided or ordered must be authenticated by the ordering practitioner
  • Handwritten or electronic signatures (stamped signatures are not acceptable)
  • Legible Signatures
Q: What should I do if I haven’t signed a medical record?
A: You cannot add late signatures to medical records (beyond the short delay that occurs during the transcription process). If the practitioner’s signature is missing from the medical record, submit an attestation statement from the author or the medical record. See a sample attestation statement below.
Q: What if the physician signs the progress note, but the signature is illegible?
A: You may submit a signature log or attestation statement to identify the illegible signature. A printed name below the illegible signature on the original record may be acceptable.
Q: Are initials acceptable as a signature?
A: You may submit a signature log or attestation statement to identify the initials. A printed name below the initials on the original record may be acceptable.
Q: What is a signature log?
A: A signature log is a typed list of all providers that displays each provider’s name with a corresponding handwritten signature. The log may be for an individual or a group. A signature log is used to establish signature identity as needed throughout the medical record documentation process.
Q: What if I do not currently have a signature log in place?
A: You may create a signature log at any time. Medicare contractors accept all signature logs submitted regardless of the date created.
Q: Can I attest to my own signature?
A: Yes. A signature attestation is a statement signed and dated by the author of the medical record entry. It must contain sufficient information to identify the beneficiary. A sample attestation statement can be found below.
Q: Do signatures need to be dated?
A: Documentation must contain enough information to determine the date on which the service was performed or ordered. If the entry immediately above or below the signature is dated, medical reviewers may reasonably assume the date of the signature in question is the same.
Q: What are the guidelines for using an electronic signature?
A:
  • Systems and software products must include protections against modification; apply administrative safeguards that correspond to standards and laws.
  • The individual named on the alternate signature method and the provider bear the responsibility for the authenticity of the attested information.
  • Physicians are encouraged to check with their attorneys and malpractice insurers with regard to the use of alternative signature methods.
Q: Can my name be printed by the software without a signature?
A: No. An unsigned, typed note with the provider’s name only does not meet the requirement.
Sample Attestation Statement:

I, (print full name of physician/practitioner), hereby attest that the medical record entry for (date of service) accurately reflects signatures/notations that I made in my capacity as (insert provider credentials, e.g., DC) when I treated/diagnosed the above-listed Medicare beneficiary. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Signature Requirement Errors

Meeting Signature Requirements

Like many of the Medicare Administrative Contractors (MACs), National Government Services (NGS) report they have experienced an increasing number of Comprehensive Error Rate Testing (CERT) errors due to “signature requirements” not being met. Medical Providers are not signing orders or certification/recertification forms. All types of providers are failing to sign office visit notes.

Medicare requires that services provided/ordered/certified must be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Most, if not all, third-party payers follow Medicare’s signature guideline policy. The treating physician’s signature on a note indicates s/he affirms that the note adequately documents the care provided. Insurance reviewers are required to look for the signature (and date) of the treating provider on the note. The physician can use either a handwritten or electronic signature.

Acceptable Types of Signature How They Meet Requirements
Full Signature Signature is clear and legible
First Initial and Last Name Signature is clear and legible
Illegible Signature Placed over a typed or printed name
Illegible signature The letterhead, addressograph, or other information on the page indicates the identity of the signatory
Illegible signature not over a typed/printed name and not on letterhead Submitted documentation is accompanied by a signature log or an attestation
Initials Placed over a typed or printed name
Initials not over a typed/printed name Accompanied by a signature log or an attestation statement
Unsigned handwritten note Other entries on the same page in same handwriting are signed
    • Handwritten Signature: A handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance, or obligation.
    • Signature Log: Typed or printed name of the author associated with initials or illegible signature. It should include the provider’s credentials and be included as part of the medical record.
    • Signature Attestation Statement: Must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary for it to be considered valid for Medicare medical review purposes.
    • Electronic Signature: The author’s e-signature, full name, credentials, date, and time of e-signing.

Note: Stamped signatures are not acceptable.

Understanding Signature and Authentication Requirements

One of the most important elements of a complete medical record is the name and signature of the provider of service. Medicare has set the standard for all payers on what is required to confirm the medical record and validate who provided the service. Most other payers follow the same guidelines as Medicare.

This training video outlines these signature requirements and how to ensure that each visit includes the mandatory information, in a legible format. Sometimes, errors can happen. We’ll summarize the options that providers have to authenticate a record, should that be necessary and how an internal signature log is one of the most important tools in your signature policy.

Medicare’s Documentation Reference Documents

Download Reference Documents Medicare publishes helpful documents and alerts to keep providers in the know about important topics. Included here are several documents that relate specifically to documentation of Chiropractic care and medical necessity. These tools relate to the elements of Chiropractic documentation and the overall rulebook for Medicare policy, The Benefit Policy Manual. Download,…

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Be the GOAT of the OATs

Which OATs are Best Suited for Your Practice? The number and variety of Outcome Assessment Tools (OATs) available today can make it difficult to decide which one to use. To be the GOAT (Greatest of All Time) you need to select the one that best evaluates each patient’s functional deficits so you can use the…

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Use of OATS to Create Effective Short Term Goals

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This content is reserved for our student Chiropractors in training!