CMS MEDICAL RECORDS SIGNATURE REQUIREMENTS
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

4/6/2011

One of the more frequent questions I have been asked over the last few months is:  What are CMS’ requirements – acceptable and unacceptable practices – for medical records signatures?  I researched this question and found my answer in the following Medicare documents:

1. The Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.4.1.1 B: http://www.cms.hhs.gov/manuals/downloads/pim83c03.pdf
2. MLN Matters Article #: MM5971: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdfMLN Matters Article #: MM5971: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdf

Additionally, for your reference, I was able to locate a very detailed account of acceptable and unacceptable practices on the Palmetto GBA Medicare website – posted below. Palmetto GBA is the Medicare contractor for California, Nevada, Ohio, West Virginia, Hawaii and South Carolina. I also thought you might find this information helpful in answering your questions:

Medicare Part B Medical Records Signature Requirements – Acceptable & Unacceptable Practices

While CMS guidelines mandate the presence of signatures specifically for all “medical review” purposes, modifiers, etc., records pertaining to ANY procedures billed to Medicare Part B are potentially subject to review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.

The contents of this article are applicable to every Medicare claim processed by Palmetto GBA on or after April 28, 2008 (for dates of service beginning with September 3, 2007).

Signature’s Purpose

Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials, e.g., P.A., D.O., or M.D.

The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate the Part B services 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.

Medicare Requirements for Valid Signatures

Acceptable methods of signing records/test orders and findings include:

• Handwritten signature

• Electronic signatures:

o Digitized signature – an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet.

o Electronic signatures usually contain date and timestamps and include printed statements, e.g., “electronically signed by,” or “verified/reviewed by,” followed by the practitioner’s name and preferably
a professional designation. Note: The responsibility and authorship related to the signature should be clearly defined in the record.

Example of an acceptable electronic signature:

“Electronically Signed By: John Doe, M.D. 08/01/2008 @ 06:26 A“

• Digital signature – an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage.

Unacceptable Signatures

• Signature “stamps” alone in medical records are NO longer recognized as valid authentication for Medicare signature purposes and may result in payment denials by Medicare.

• Reports or any records that are dictated and/or transcribed, but do not include valid signatures “finalizing and approving” the documents are not acceptable for reimbursement purposes. Corresponding claims for these services will be denied.

NOTE: Be aware that electronic and digital signatures are not the same as “auto-authentication" or "auto-signature" systems, some of which do not mandate or permit the provider to review an entry before signing. Indications that a document has been “signed but not read” are not acceptable as part of the medical record.

For reference and exceptions, please refer to the Medicare documents listed above.

The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.