Knowledge Base Article

Medicare requires that practitioners ordering or providing services authenticate their orders and other documentation notes. A simple enough concept, but sometimes it is the simple things that seem to trip us up. Medicare reviews often cite lack of physicians’ signatures on orders, procedure notes, diagnostic reports or progress notes as a documentation deficiency that could result in a denial of payment. A review of Medicare signature requirements is an excellent reminder of the basics of good documentation.

What forms of signatures are acceptable?

Signatures may be handwritten or electronic. Stamped signatures generally are not acceptable, but are permitted in the case of an author with a physical disability who can provide proof to a CMS contractor of inability to sign due to the disability.

Can signatures be added to documentation that is not signed?

No. Providers may not add late signatures to medical records beyond the short delay that occurs during the transcription process.

Medicare does not accept retroactive orders. If an order is unsigned and there are no signed progress notes that specify the tests/services being ordered, a Medicare reviewer will disregard the order. This will result in a documentation error, which may involve recoupment of an overpayment.

For other types of medical record documentation that lack a signature besides orders, an attestation statement from the author of the medical record may be submitted. An attestation may read as follows, though no specific format is required:

            “I, John R. Doe (printed name), hereby attest that the medical record entry for March 9, 2016 accurately reflects signatures/notations that I made in my capacity as M.D. 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.”

Must orders for clinical diagnostic tests be signed?

No - but yes. The order for a clinical diagnostic test does not have to be signed. However, if the order itself is not signed, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the clinical diagnostic test be performed. The documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. It also must specify the tests ordered; simply saying “labs ordered” is not sufficient. And, a copy of this signed documentation must be submitted to the Medicare contractor in the case of a Medicare review.

What if a signature is illegible?

If there is a printed signature below the illegible signature, this is acceptable. Providers can also submit a signature log to address illegible signatures. A signature log should list the typed or printed name of the author associated with the author’s handwritten initials or signature. Note that providers may create and submit a signature log at any time. It is a good practice to maintain a signature log of all practitioners.

Another way to address illegible signatures is an attestation statement. The attestation must be signed and dated by the author of the medical record entry in order to be valid for Medicare medical review purposes. It also must contain sufficient information to identify the Medicare patient/beneficiary.

Must signatures be dated?

It depends. If Medicare regulations specify that a date is required for the particular type of documentation then it must be dated. For example, for rehabilitative therapy services, the Medicare Benefit Policy manual states, “Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.” Therefore, for therapy certifications, a dated signature is required.

If the Medicare regulations do not specify that a date is required, undated documentation may be acceptable. Documentation that is not dated is acceptable for medical review purposes if the reviewer is able to determine the date the service was performed and/or ordered based on other documentation in the record.

Since the issue of missing and illegible signatures continues to be a common error, Medicare provides a variety of resources addressing the requirements. Providers must get back to the basics of documentation by ensuring appropriate signatures are present.

• Medicare Signature Requirements – Educational Resources for Health Care Professionals: SE1419
• Medicare Signature Requirements Fact Sheet: Fact Sheet
• Chapter 3, Section 3.3.2.4, Medicare Program Integrity Manual
• Signature Guidelines for Medical Review Purposes: MM6698