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FAQs Concerning Physician's Signatures

Where does it say documentation must be signed?

Guidelines surrounding signature requirements can be found in the Medicare Internet Only Manual (IOM) Publication 100-2, Ch3, sect 3.4.1.1(b)

Please note that all services ordered or rendered to Medicare beneficiaries must have a signature. While orders for diagnostic tests do not have to be signed, either the order must have a signature or the intent to order the specific test must be clearly documented in the medical record, and that must be signed. One or the other must be signed.

What is considered an acceptable signature?

Signatures can be handwritten and/or electronically signed – STAMPED SIGNATURES ARE NOT ACCEPTABLE. If handwritten it must be legible or have a signature line with a typed and/or printed version of the name of the person signing. If electronic, the signature must include a phrase similar to "electronically signed by, reviewed by, etc." and may include the date and time of the signature.

Please note that only the person actually performing the service can sign the documentation. A partner or provider covering for another cannot sign the order, record or attestation statement.

If I inadvertently forget to sign a note what should I do?

You should not add a late signature to the medical record but instead make use of the signature authentication process that was recently issued in Change Request (CR) 6698 which allows the use of an attestation statement by the performing provider to resolve illegible or missing signatures. A sample attestation statement can be found on our websitePDF.

What about HIPAA requirements?

The forwarding of such specifically requested records to the designated contractor is required and does NOT violate privacy provisions under the HIPAA law. The Centers for Medicare & Medicaid Services (CMS) has contracted with CGS, the CERT Documentation Contractor, and the CERT Review Contractor to conduct the activities within the Medicare program. As a Medicare contractor and in accordance with Section 1816 and 1842 of the Social Security Act, CGS and the CERT contractors are authorized to request claims and medical records from providers and suppliers of Medicare services. Physicians, providers and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated contractor.

Should you receive a letter from CMS regarding a CERT request for medical documentation, or from CGS requesting medical documentation, you should respond promptly by submitting the requested supporting documentation within the time frame outlined in the request.

Is an approved authorization necessary?

Physicians, providers and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated contractor.

What happens if I do not submit an attestation?

Your payment for the services in question will be recouped.

Section 1833(e) of the Social Security Act states that we must have sufficient information to determine the identity of the provider performing the service. The valid signature is the method used to make this determination. Not submitting a valid signature, or the attestation, upon request is the same as having no documentation, and we have no choice but to recoup any monies paid incorrectly. It would be prudent for providers to form the habit of signing all documentation.

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