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Linda Collins Blogger

The Quest for Legible Signatures

Posted by Linda Collins | August 17, 2012

Medicare administrative contractors (“MACs”) are cracking down on signatures and certifications. Recent examples from the Comprehensive Error Rate Testing Program (“CERT”) indicates that claims are being denied for illegible practitioner signatures, illegible physician signatures, notes with no identifying practitioner, and signatures without dates or credentials.

According to CMS, in order for a signature to be valid, the following criteria must be met:

  • Services that are provided or ordered must be authenticated by the ordering  practitioner;
  • Signatures are handwritten or electronic (stamped signatures are not acceptable); and
  • Signatures are legible.

Reference: CMS “Medicare Program Integrity Manual” (Publication [Pub.]100-08), Chapter 3, Section 3.4.1.1.D

So in addition to assuring all clinical documentation is received, a practitioner must make sure all progress notes and reports are dated and signed with credentials. For more information go to Medicare Learning Network’s® MLN Matters® Article MM6698, “Signature Guidelines for Medical Review Purposes”

How does this relate to RAC audits and prepayment claim reviews? Based upon these CERT results, it appears that the MACs and RACs are getting ever more particular about strict technical compliance with things such as legibility requirements. The RACs, in particular, may look especially closely at these kinds of issues given the fact that they get paid a percentage of the money they recover.

So what can you do? Make sure you have standard charting procedures in place and always verify the legibility of all signatures before submitting your claim. Being able to read someone’s handwriting is an increasingly essential element in responding successfully to a RAC audit or a prepayment claim review. And, like it or not, it’s a clear Medicare requirement.

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