Posts Tagged ‘signature’

CMS Signature Requirements – A Reminder for Compliant Records

In Uncategorized on August 22, 2013 at 6:24 pm

As we all know, there are certain signature requirements imposed by CMS and other payers.  The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated.  Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.   Such signature must be legible and should include the practitioner’s first and last name.  For clarification purposes, it is recommended that providers include their applicable credentials (e.g., P.A., D.O., or M.D.).

These signatures can be electronic or written – both of which have a set of acceptable formats.  Examples of acceptable written signatures are:  legible fill signature, legible first initial and last name, illegible signature over a typed or printed name, illegible signature on letterhead that otherwise identifies the signatory (if multiple providers on letterhead, the signatory’s name must be circled), etc….[1]  Conversely, an illegible signature with no accompanying typed or printed name or letterhead is unacceptable absent an attestation statement. 

Occasionally we have seen situations in which a carrier seeks additional information in the form of notes, which are deemed illegible.  In this case, it is advisable for your billing company to have on file an attestation statement confirming the nature of that illegible signature.  This is key because once your billing company has been asked for this attestation statement, you are only allowed 20 calendar days in which to provide it.  Such statement must include the following components:

  • the full printed name of the provider
  • sufficient information to identify the beneficiary
  • date of service
  • signature and date by the author of the medical record entry (i.e., generally the provider)

In order to expedite the submission of such requests, it behooves you to provide your billing company with an executed blank signature attestation statement that the billing company can keep on file for future use.