How to Sign Records, Orders, and Findings

One of the requirements of Medicare and other payers is that each medical service ordered and provided must be “authenticated by the author.” This means that it must be signed by the clinician doing the ordering or performing the procedure. A payer may deny a claim for payment if the medical record is not properly authenticated. The Centers for Medicare & Medicaid Services (CMS) recently issued a MedLearn Matters article (MM6698) on “Signature Guidelines for Medical Review Purposes,” in which their auditors are told what to look for regarding signatures. (The article is available at www.cms.gov/MLNMattersArticles/dowloads/MM6698.pdf)

Medicare’s Rules on Signatures

The MedLearn Matters article contains the following guidance for clinicians. A handwritten signature is defined as a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation. Acceptable methods of signing records/test orders and findings include handwritten signatures or initials and electronic signatures. Signature stamps are not acceptable.

Facsimiles of original written or electronic signatures are acceptable for notes that are used for certification of terminal illness for hospice. Although orders for clinical diagnostic tests do not require a signature, there must be medical documentation for an unsigned order for the test by the treating clinician (ie, a progress note) that he/she intended for the clinical test to be performed. This documentation showing intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. Note also that other regulations and CMS instructions regarding signatures take precedence. If a regulation, National Coverage Determination (NCD), Local Coverage Determination (LCD), or the CMS manual has specific signature requirements, those requirements take precedence.

If a regulation, NCD, LCD, or the CMS manual is silent on whether the signature must be legible or present and the signature is illegible or missing, the auditor will follow the following guidelines to determine the identity and credentials of the signatory.

Guidelines on Signatures

Auditors are instructed to use the following guidelines regarding signatures. 

1. If there are reasons for denial unrelated to the signature requirements, the reviewer need not proceed to signature authentication. If the criteria in the relevant Medicare policy cannot be met but for a key piece of medical documentation that contains a missing or illegible signature, the reviewer shall proceed to the signature assessment.
2. Providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process but may make use of the signature authentication process. Providers may submit signature logs or attestation statements, as discussed below.
3. If the signature is illegible, auditors shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
4. If a signature is missing from an order, auditors shall disregard the order during the review of the claim.
5. If the signature is missing from any other medical documentation, the auditor shall accept a signature attestation from the author of the medical record entry.
6. For medical review purposes, if a relevant regulation, coverage determination, or manual is silent on whether the signature must be dated, the reviewer shall review to ensure the documentation contains enough information for the reviewer to determine the date on which the service was performed or ordered. Here is an example. The claim being reviewed is a hospital visit on October 4. The response to the documentation request is a page from the hospital medical record containing three entries. The first entry is dated October 4 and is a physical therapy note.

The second entry is the undated physician visit note. The third entry is a nursing note dated October 4. The reviewer may conclude that the physician visit was conducted on October 4.

Signature Logs

Providers sometimes include a signature log that identifies the author associated with the initials or an illegible signature in the documentation they submit. The signature log might be included on the page where the initials or illegible signature are used or might be a separate document. Reviewers will consider all submitted signature logs regardless of the date they were created. 

Attestation Statements

Providers sometimes include an attestation statement in the documentation they submit. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. An accepted format for an attestation statement is as follows:

“I, [name of provider], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [provider credentials] 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.”

Claims reviewers will not consider attestation statements where there is no associated medical record entry or from someone other than the author of the medical record entry in question. 

Electronic Prescribing

Reviewers will accept as valid any order for Part B drugs through a qualified E-Prescribing system. When Part B drugs have been ordered through a qualified E-Prescribing system, the reviewer will not require the provider to produce a hardcopy pen and ink signature as evidence of a drug order. For Medicare review purposes, a qualified E-Prescribing system is one that meets all 42 CFR 423.160 requirements. (For the rules regarding electronic prescribing of controlled substances, visit www.deadiversion.usdoj.gov/ecomm/e_rx/index.html)

Contractor Requirements Regarding Signatures

Medicare contractors may have signature requirements in addition to those described above. For example, the following requirements are from Palmetto GBA.
 (See www.palmettogba.com/palmetto/providers.nsf/vMasterDID/84HT746343?opendocument)

The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend inclusion of applicable credentials, eg, PA, DO, or MD.

Electronic signatures usually contain date and time stamps and include printed statements, eg, “electronically signed by” or “verified/reviewed by,” followed by the practitioner’s name and preferably a professional designation.

Note that the responsibility and authorship related to the signature should be clearly defined in the record.

I have chosen to provide this information because it would be a shame for a nurse practitioner to spend time writing a detailed note, only to have the claim for payment denied because of a signature problem.