Medical Documentation Signature Requirements

Medical Documentation Signature Requirements
Missing Signature
Illegible Signature
Signatures for Amendments, Corrections and Delayed Entries
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Medical Documentation Signature Requirements

For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by those responsible for the care of the beneficiary in accordance with Medicare regulations. The method used must be a handwritten or an electronic signature. Stamped signatures are not acceptable (with exception outlined below). The credentials of the clinician authoring the documentation and the date of signing should be included to complete the signature process.

The signature requirement applies to all documentation submitted in response to an ADR for medical review purposes. This includes (but not limited to) certifications, treatment plans, orders, progress notes, face-to-face encounters, evaluations, and medication administration records. Note: If signed electronically – it must be clearly identifiable that the signature was indeed electronic and not typed.

For a signature to be valid, the following criteria must be met:

The author must authenticate documentation of services provided or ordered.
Signatures are handwritten or electronic (stamped signatures are only 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 a disability in accordance with the Rehabilitation Act of 1973).
Handwritten signatures and dates are legible (ICN 905364 March 2016)
- If the handwritten signature is illegible, supporting evidence in a signature log, attestation statement or other documentation will be given consideration to determine the author’s identity.

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ordered. (CR 9225)

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Missing Signature

Providers should not add late signatures to the medical record, other than those that result from a short delay during the transcription process. Providers should use the signature attestation process, when permitted. Medicare does not accept retroactive orders. If the signature is missing from an order, the order shall be disregarded during the claim review. If the signature is missing from any other medical record documentation, a signature attestation will be accepted from the author of the medical record entry.

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Illegible Signature

In the case of an illegible signature, the provider may submit a signature log or attestation to support the identity of the signer. Medical Review staff will review the medical record documentation submitted for a clear legible signature by the illegible signature’s author to verify their identity. A signature log is a typed list of provider names, each name matched with that provider’s handwritten signature. The signature log can be used to establish signature legibility as needed throughout the medical record documentation. It may include the complete signature of the provider, as well as initials, documented by the provider one or more times to show variations in the signature. Medical Review also encourages providers to include their professional credentials/titles on the signature log.

Medical Review will accept all submitted signature logs, regardless of the date of creation.

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Signatures for Amendments, Corrections and Delayed Entries

All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally certain entries are not properly documented and will need to be amended, corrected or entered after rendering the service. Health record documents submitted containing amendments, corrections, or addenda must clearly and permanently be identified as such, clearly indicate the date and author of the entry, and must clearly identify all original content without deletion. When correcting a paper medical record, amendments or delayed entries may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name. When correcting electronic health records, entries must reliably identify the original content, the modified content and the date and author of each entry in the record.

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Medical Documentation Signature Requirements

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