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March 6, 2014Reviewed: 12.13.23

Signatures and Compliance: Practitioner Offices and Billing Services

It is fairly common knowledge that Medicare requires medical records for services provided and ordered to be "authenticated" by the author. How do these rules apply when the practitioner contracts with a billing service to submit claims and handle documentation requests? Medicare contractors apply the signature guidelines without regard to whether the practitioner, provider, or practice submits its own claims or utilizes a billing service. Regardless of who submits the claim or in what manner it is submitted (paper or electronic), and regardless of whether the provider uses an Electronic Medical Record (EMR) system or a paper-based system, Medicare's signature guidelines apply.

Compliance with Medicare's signature guidelines requires a partnership and close communication between health care providers and billing services.

Denials and Payment Delays

Failure to submit medical records with a valid signature is one of the top reasons for claim denials and payment delays, nation-wide. This is also one of the most easily preventable denial reasons. All health care providers should be aware of the increased level of scrutiny regarding signatures in medical records and take steps to ensure they have procedures in place to address this critical issue.

Special tips for billing services:

  • CGS strongly recommends that, before you submit a claim or any medical records that have been requested, you ensure that the medical records for that specific service meet Medicare's guidelines for signatures. This tip applies for record requests from CGS, the Recovery Auditor, Comprehensive Error Rate Testing (CERT) contractor, and the Zone Program Integrity Contractor (ZPIC).
    • If the records are not signed or do not meet Medicare's signature guidelines, contact the provider of service and request that he/she sign an attestation.
    • If the claim has not been filed yet, file the completed attestation with the patient's medical records.
    • If the claim has already been filed:
      • Submit the signed attestation with the records.
      • Ensure the records are complete (check front/back of records, if using paper records).
      • Do not copy the patient's entire file; only send the relevant portions that are related to the request.
    • For more tips on submitting medical records, refer to the CGS web article "Medical Record Requests: Keys to Success."

Important notes for practitioners and providers that utilize a billing service:

  • If your billing service is responsible for submitting claims as well as handling requests for medical records, be aware that the service may contact you to request a signature attestation. We encourage you to be responsive to these time-sensitive requests to avoid delays or denial of payment. Signature attestation requests require a response within 20 days of the date CGS faxes the request.
  • You can avoid requests for signature attestations by implementing a signature process that meets Medicare's requirements and checking your medical records for valid signatures before you send them to billing.
  • If you use Electronic Medical Records, we suggest you advise your billing service not to submit claims until your electronic signature has been added to the records.
  • Ensure that the contact information in your PECOS record with Medicare is current and complete. This will assist CGS if we need to contact you or your billing service to request additional information (such as a signature attestation).
  • We strongly recommend you discuss your expectations with your billing service and ensure that there is a point of contact in place for handling questions.


A valid signature, for Medicare purposes:

  • Is legible
  • Contains your professional DESIGNATION (e.g., MD, DO, NP)
  • Contains the date you signed

A valid signature attestation, for Medicare purposes is:

  • Legible
  • Complete with:
    • Beneficiary information (CGS asks for name/date of birth)
    • Legibly printed provider name
    • Date of service you are attesting to
      • ONE date of service per attestation
    • Professional designation (e.g., MD, DO, NP)
    • Handwritten signature of provider
    • Date the attestation was signed

Hand-written versus electronic signatures: guidance on what is acceptable

  • Legible handwritten signatures or initials
    • Handwritten signatures should be legible and the reviewer must be able to determine whose signature is used.
  • Electronic signatures should contain date, time stamp, and include printed statements, e.g., "electronically signed by," or "verified/reviewed by," followed by the practitioner's name and preferably a professional designation.
  • Digitized signature: an electronic image is an individual's handwritten signature reproduced in its identical form using a pen tablet.  This is an "actual" real time signature done electronically, like the digital sign-out with a credit card transaction.
    • Note: if using the digitized signature method of a written signature that is typically generated by special encrypted software that allows for sole usage, and you are submitting medical records based on a request from CGS or another Medicare contractor, also submit your protocol outlining the guidelines followed by each user.
    • An electronic image is an individual's handwritten signature reproduced in its identical form using a pen tablet
    • An "actual" real time signature done electronically, like the digital sign-out with a credit card transaction
  • Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-signature' systems, some of which do not mandate or permit the provider to review an entry before signing.
  • "Signature on file" is not acceptable in medical records and does not constitute a valid electronic signature.



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