WPS Medicare Guidance on Provider Signature Requirements for Medical Documentation

The issue of illegible and missing/invalid signatures is currently a hot topic with CMS and various other Medicare contractors. With only a few exceptions, Medicare regulations require that the individual practitioner who ordered or provided services be clearly identified and validated through a signature in the medical record documentation. The Internet-Only Manual (IOM), Publication 100-08, Program Integrity Manual, Chapter 3, Section 3.4.1.1, states:

Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

It is crucial that medical record documentation be validated promptly with a signature by the practitioner who is responsible for providing, evaluating, or ordering the service(s) rendered. If required and there is no signature present in the documentation, this will result in claim denials upon review. This applies to all providers, including those in solo practices.

Guidelines for Valid Provider Signatures

Handwritten Notes or Orders
Handwritten signatures must be legible. It is recommended that providers sign documentation using their first and last name. If the letters in the signature are not easily read, it would be advantageous to also include a signature sample when responding to requests for medical records. This will help ensure that claims are not denied because the person providing the service cannot be determined due to an illegible signature.

Electronic Notes or Orders (excluding E-prescribing)
An electronic signature validates an electronic medical record (EMR) in the same way as a hand written signature validates a written medical record. The IOM states:

Providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws.

The IOM further iterates that providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. With the use of an electronic signature, the individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested. It is encouraged that physicians check with their attorneys and malpractice insurers regarding the use of alternative signature methods. If a recognizable electronic signature is not apparent on the EMR, this could result in claims being denied.

Please remember…for medical record documentation and validation, all State licensure and State practice regulations continue to apply. Where State law is more restrictive than Medicare, the contractor needs to apply the State law standard.

Page Last Updated: Thursday, 18-Mar-2010 05:49:13 CDT