December 23, 2025
Recently Part B Medical Review has noticed an uptick in late signatures and improperly completed amendments/delayed entries in medical documentation.
Per CMS, if a required signature is missing from a medical record noted after receiving an Additional Documentation Request (ADR), the appropriate course of action is to file an attestation statement rather than signing the medical record after receiving the request. Medicare Administrative Contractors (MACs) accept signature attestations for all medical documentation except orders when required. The attestation must be associated with a medical record and created by the record’s author. We may consider attestations, regardless of their creation date.
Also, CMS has information regarding amendments and delayed entries in medical documentation in the Internet Only Manual (IOM) Program Integrity Manual, Chapter 3, Section 3.3.2.5. Per the Program Integrity Manual, “All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided may not be properly documented. In this scenario, the documentation may need to be amended, corrected, or entered after rendering the service. The date and author of any amendment, correction or delayed entry should be identifiable, and the change/addenda should be clearly and permanently denoted.” Amendments and delayed entries should only occasionally be completed and should not be completed after ADRs are issued. Also, they must be properly identified as an amendment, dated, and authored.
For additional information regarding signatures and amendments/delayed entries please refer to:
Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 - Signature Requirements![]()
Complying with Medicare Signature Requirements - MLN Fact Sheet![]()

