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Signatures

CGS is still seeing an increase in errors due to inadequate provider signatures on documentation submitted for medical review. Documentation must support the medical necessity of the services provided but without the proper signature of the rendering/billing provider, records cannot be validated and services will be denied. The Program Integrity Manual ( PUB 100-8), Ch. 3, section 3.4.1.1, states "Medicare requires a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes."

Signatures must be legible and handwritten or electronic and should include the provider's first and last name.

These forms of signature documentation are not acceptable and will be considered errors upon review:

  • Signed but not read
  • Signed before reading
  • Dictated by
  • Electronically signed and sent without review to avoid delay
  • Signature on file
  • Provider name typed but not signed

Acceptable forms of signature are as follows:

  1. Handwritten: Handwritten signatures must be legible; many records we received cannot be verified to be that of the provider due to illegibility. If the signature is illegible, a signature card or sample of his/her signature with his/her name printed/typed beside it should be included with the requested documentation.
  2. Electronic: An electronic signature is part of an electronic record and must be executed by the person who performs the service. This form of signature must adhere to security standards in the Health Insurance Portability and Accountability Act (HIPAA). In the instance of an electronic signature, the record will state one of the following, along with the typed name of person signing record:
    • Electronically signed by
    • Electronically verified by
    • Reviewed by
    • Authenticated by
  3. Digital: An electronic image is an individual's handwritten signature reproduced in its identical form using a pen tablet. (Note; this is an "actual" real time signature done electronically, like the digital sign-out with a credit card transaction) If using the digitized signature method of a written signature that is typically generated by special encrypted software that allows for sole usage, also submit your protocol outlining the guidelines followed by each user.

The legible (signature) identifier requirement applies to documentation for ANY service performed and billed to Medicare.

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