Reminders for Submitting Documentation
What Documentation to Submit When a Request for Records is Received
- Documentation to support the medical necessity of the service rendered
- Documentation that the procedure/service was ordered/performed and by whom
- Documentation that reflects the correct patient name and date of service identified on the claim
Signature requirements are outlined in the Internet Only Manuals; Pub 100-8, Ch 3, sect 3.4.1.1.
- ALWAYS sign your notes/orders – submitted records with just a typed signature/signature line with no handwritten or electronic signature are not acceptable
- Signatures must be legible – a signature where no letters can be established is not acceptable
- ALWAYS print your name along with your written signature for clarification
- Initials must also have a printed or typed name for clarification - when a note is from an inpatient setting, a full signature is preferred along with a printed name
- Notes that have been transcribed should always be reviewed and signed – either electronically or with a hand-written signature - by the author of the note.
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.
Physicians' orders are outlined in the Internet Only Manuals; Pub 100-2, Ch 15, sect 80.6
When ordering lab work there must be one of the following:
- An office note where the ordering physician wrote which labs were to be performed, which must be signed and dated, and must be legible
- A requisition signed and dated by the ordering physician; the signature and date must be legible
- Always include a sample signature sheet for authentication of illegible signatures.
Keep in mind that while the lab request itself does not require a signature, there must be a signature in at least one of two places – either on the office note in which the intent to order the test was clearly documented, or on the requisition or lab order slip.
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