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Legible Identifier (Signature) Requirements for Appropriate Billing to Medicare

This notice is intended to help providers understand that an error will be assessed when a medical record does not include a LEGIBLE IDENTIFIER (signature) of the author (initials are not acceptable).

This error will cause an overpayment and a recoupment of funds.

Through audits conducted by the Office of Inspector General (OIG) and CERT (Comprehensive Error Rate Testing) there appears to be little compliance to the signature requirements outlined in the Internet Only Manuals, Pub 100-8, Ch 3, Sec 3.3.2.4.

Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purpose...

The OIG and CERT have made it clear that this requirement must be enforced and signatures (initials are not acceptable), hand written or electronic, must be present on ALL documentation and MUST BE LEGIBLE.

To avoid an error for signature reasons, we recommend that you make certain your documentation contains a LEGIBLE IDENTIFIER (signature) or valid electronic signature (initials are not acceptable) of the person performing the service and include a signature sample when responding to a request for records.

The legible (signature) identifier (initials are not acceptable) requirement applies to documentation for ANY service performed and billed to Medicare.

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