Increase in Documentation Submitted Without a Valid Provider Signature Affects Payments

National Government Services (NGS) is reporting an increase in documentation submitted without valid provider signature identification. This leads to claim denials that require time-consuming appeals.

All medical records must have either a written or electronically entered provider signature. When that signature is not legible, records should be submitted with a signature log, with the provider’s name printed or typed and accompanied by a signature.

WCH reminds providers of long-standing Centers for Medicare & Medicaid Services (CMS) signature requirements for all paper and electronic medical records:

MISSING OR ILLEGIBLE SIGNATURES/SIGNATURE REQUIREMENTS

Posted on www.ngsmedicare.com, 6/8/2017)

CMS issued revised Change Request 6698 to clarify how Medicare contractors review Medicare claims and medical documentation submitted by physicians and/or providers. Medicare requires that services provided/ordered be authenticated by the author. The method used for authenticating shall be a handwritten or electronic signature. Stamped signatures are not acceptable.

National Government Services encourages physicians and providers to verify that a legible signature is present on all medical records during their quality check before the document is filed in the patient’s permanent record. Unsigned documentation or lack of attestation will result in the denial of services.

Acceptable Electronic Signatures

• Chart “Accepted by” with provider's name
• “Electronically signed by” with provider's name
• “Verified by” with provider's name
• “Reviewed by” with provider's name
• “Released by” with provider's name
• “Signed before import by” with provider's name
• Digitalized signature: Handwritten and scanned into the computer
• “This is an electronically verified report by John Doe, MD”
• “Authenticated by John Doe, MD”
• “Authorized by: John Doe, MD”
• “Digital Signature: John Doe, MD”
• “Confirmed by” with provider's name
• “Closed by” with provider's name
• “Finalized by” with provider's name
• “Electronically approved by” with provider's name
•  

Examples of medical records that require a legible signature:

• Dictated reports (provider should proofread the dictation)
• Outpatient visits
• Laboratory or diagnostic orders/requisitions (if you are unable to obtain a copy of the physician’s progress notes requesting the test to be performed)
• Certificates of Medical Necessity (CMNs)
• Treatment plans/plan of care
• Treatment log notes
• Initial evaluations or current re-evaluations
• Inpatient visits (if necessary obtain the signed copy from the hospital)
• Office visits (even if there is only one provider at the practice location)

Note: If you notice the signature is illegible when asked to supply medical records, please include a signature key, signature page, or a document from the provider/physician or compliance officer that affirms the signature is indeed the provider’s/physician’s. This signature document can be submitted routinely for all requests for medical records.

Click here for more information. Scroll to 3.3.2.4 - Signature Requirements