The Centers for Medicare & Medicaid Services (CMS) recently published new guidance on what constitutes a legible signature. An alphabet soup of auditors (MICs, RACs, CERTs and ZPICs) have been contracted to find and recover Medicare overpayments – like money paid for services when the documentation has no legible signature – so you should familiarize yourself with the rules.
For medical review purposes, Medicare requires that signatures for services provided or ordered be authenticated by the author with a handwritten or electronic signature. Stamped signatures and typed names without a signature are not acceptable.
If medical records are requested for review and you find that signatures are missing or illegible, do not add late signatures (beyond the delay that occurs during the transcription process). Instead, provide a signature log or attestation statement in support of the records.
A signature log contains the full name and credentials or title of everyone in the practice who might write in a medical record, their signature as they usually sign and any other forms of signature they might use (e.g., initials), and the date. If you don't want to create a comprehensive signature log for the practice, a simple one could be included as a separate entry on the actual page where the initials or illegible signature were used. (Tip: A list of commonly used abbreviations may provide additional support for your documentation, as these can be a source of confusion for auditors.)
An attestation statement is a signed statement that may be sent with unsigned medical documentation to attest that the services were performed and documented by the person who signs the attestation statement. This example is provided in the CMS guidance:
"I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., MD] 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."
The attestation statement must contain sufficient information to identify the patient. Be sure to include the patient's name and insurance number.
Records or orders signed with a squiggle or what sometimes appeared to be the output from an ECG are giving way to electronic signatures generated by electronic health record systems, but even electronic signatures must be used correctly. Providers using electronic systems need to use software products and administrative procedures that protect against modification and comply with recognized standards and laws.
One final note from the CMS guidance: If reviewers identify a pattern of missing or illegible signatures, it will be referred to the appropriate program integrity contractor for further development.
Don't let something as easy to correct as a missing or illegible signature allow the auditors to take back money you earned.
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