How to Verify QMB Status

Verifying QMB Statuses… Medicare Qualified Beneficiaries (QMBs) hold special status when it comes to cost-sharing in your office. It’s important to identify them carefully before any financial transactions take place.  In 2017 CMS set up a system to help clinics and clearinghouses verify status. The system is called the HIPAA Eligibility Transaction System (HETS).  While…

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Managing Dual Eligible Medicare Beneficiaries

How to Manage Dual Eligible Medicare Beneficiaries The Medicare Savings Programs (MSPs) was developed to assist low-income Medicare beneficiaries. Individuals who qualify for this assistance are often referred to as “Dual Eligibles”. All dual-eligible beneficiaries qualify for full Medicare benefits, but the extent or level of benefits for which they are eligible under Medicaid can…

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Medicare Reference Documents-Signature Guidelines

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 the rules of properly signing the medical record notes of patients.  These tools relate to the elements of signatures, authentication, and attestation, should that be necessary. We’ve also provided a sample of one Medicare Administrative Contractor’s (MAC) guidelines for your reference.

Download, study, and save these documents in your Medicare training materials as an essential references for Chiropractic Medicare.

Sample Signature Guidelines
for Medical Record Documentation: First Coast Service Options		 Medicare Signature
Requirements – Educational Resources for Health Care Professionals
Complying with Medicare Signature Guidelines

Signature Verification Form

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Mistakes happen. Unintentional errors that include unsigned notes or notes that are not signed in a timely fashion are inevitable in a busy office. Because signatures are a requirement, once the error is found, it’s critical to correct it, learn from it, re-train, and check again.

A Signature Log is a very helpful tool to keep on file in your office compliance program. Should you need to authenticate a health record note, after the fact, this tool will be invaluable.

Download, save and use this signature log, as recommended in the introductory training video. Set yourself up to win by having the signatures on file of all providers of service.

Signature Verification Form

Signature Self-Audit Tool

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One of the most effective ways to ensure compliance is to perform periodic self-audits. These important self-checks are even a requirement of an office compliance program. By performing a retrospective review of a sampling of signed visits, you will establish a baseline of your current compliance with the signature guidelines.

Download, review and use this tool to review a collection of notes. Score your findings on this form, and if you are working with a specialist in one of our one-on-one training programs, please return this completed audit form to them. If not, use the results to inform changes that may need to be made in your signature process.

File this completed form with your compliance audit results and schedule the next self-check on signatures depending on how many errors were found. If you had multiple errors, assign key personnel and providers to review this module, and then re-audit in 30 days. If your results were good, schedule another self-check in 3-6 months.

Signature Audit Tool

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.