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Acceptable Electronic Signatures Reminder

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Acceptable Electronic Signatures Reminder

CMS issued CR6698 to clarify how Medicare claims review contractors review claims and medical documentation submitted by providers; this includes EHR. The previous language in the CMS IOM Publication 100-08, Medicare Program Integrity Manual required a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical records documentation for medical review purposes.

MLN Matters MM6698: Signature Guidelines for Medical Review Purposes revised the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 and the current language requires that services provided/ordered be authenticated by the author. The manual was revised to include examples of handwritten signatures and an example of an attestation statement, but no examples of electronic signature.

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Examples of Acceptable Electronic Signature

  • Chart “Accepted by” with provider’s name
  • “Electronically signed by” with provider’s name
  • “Verified by” with provider’s name
  • “Reviewed by” with provider’s name
  • “Released by” with provider’s name
  • “Signed before import by” with provider’s name
  • Digitized signature: Handwritten and scanned into the computer
  • “This is an electronically verified report by John Smith, MD
  • “Authenticated by John Smith, MD”
  • “Authorized by: John Smith, MD”
  • “Digital Signature: John Smith, MD”
  • “Confirmed by” with provider’s name
  • “Closed by” with provider’s name
  • “Finalized by” with provider’s name
  • “Electronically approved by” with provider’s name

When you submit medical records to a Medicare contractor with an electronic signature, you must also include a copy of the electronic signature protocol/procedure. The protocol/procedure should describe the requirements that the physician uses his own ID and password to enter the system to sign the medical records.

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Examples

The electronic signature is not dated and does not identify the physician:

  • Plan of care is reviewed and discussed with nursing staff
  • Author: nurse – physician (e-signed)

The electronic signature does not identify the physician:

  • Monitor closely
  • Author nurse – physician (e-signed)
  • Date: 3/10/2019

Reviewed 8/28/2024