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Linda Collins Blogger

Frequently Asked Questions about Signatures

Posted by Linda Collins | January 12, 2016

The Medicare Administrative Contractors (“MACs”) are cracking down on signatures and certifications. Recent examples from the Comprehensive Error Rate Testing Program (“CERT”) show that Medicare will deny claims with illegible practitioner signatures, illegible physician signatures, notes with no identifying practitioner, and signatures without dates or credentials.

What does this mean for you?

The little things matter a lot when it comes to Medicare claims. Here are 5 key things to remember about signatures on medical records.

  1. Stamped signatures are not acceptable.

  2. All signatures must be legible. If a signature is illegible, you may submit a signature log or attestation statement to support the identity of the illegible signature. If the original record contains a printed signature below the illegible signature, this may be accepted.

  3. A signature log is a typed listing of the provider(s) identifying their name with a corresponding handwritten signature. This may be an individual log or a group log.

  4. The author of the medical record entry at issue must sign and date any attestation statement. The attestation must also contain sufficient information to identify the patient.

    EXAMPLE: “I _(print full name of the physician/practitioner)___ , hereby attest that the medical record entry for ___(date of service)__accurately reflects signature/notations that I made in my capacity as ___(insert provider credentials, e.g. 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.”

  5. Documentation must contain enough information to determine the date on which the service was performed or ordered. If the entry immediately above or below the entry is dated, medical review may reasonably assume the date of the entry in question.

Reference: CMS “Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 3.3.2.4.H

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