Signature Requirements
National Government Services has experienced an increasing number of CERT errors due to “signature requirements” not being met. Providers are not signing orders, certification/recertification forms or office visit notes.
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. The treating physician’s/NPP's signature on a note indicates the physician/NPP affirms the note adequately documents the care provided. Reviewers are required to look for the signature (and date) of the treating physician/NPP on the note. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.
Below is a list of where signature requirements have been met:
- Legible full signature
- Legible first initial and last name
- Illegible signature over a typed or printed name
- Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signatory
- Illegible signature not over a typed/printed name and not on letterhead, but the submitted documentation is accompanied by a signature log or an attestation
- Initials over a typed or printed name
- Initials not over a typed/printed name but accompanied by a signature log or an attestation statement
- Unsigned handwritten note, where other entries on the same page in same handwriting are signed
Handwritten Signature: A handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance or obligation.
Signature Log: Typed or printed name of the author associated with initials or illegible signature, should include the providers credentials and be included as part of the medical record.
Signature Attestation Statement: 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.
Electronic Signature: The author’s e-signature, full name, credentials, date and time of e-signing.