Progress Note Signature Requirements

Providers should not add late signatures to medical records, except those resulting from the short delay that occurs during the transcription process. Suppliers must use the proof of signature process. Medicare does not accept retroactive prescriptions. A signature log is a typed list of vendor names followed by a handwritten signature. A signature protocol may be used to establish the legibility of the signature as required in the documentation of the medical record. MR encourages providers to also include their professional qualifications/credentials in the signing protocol. Security measures must be taken to protect your electronic signatures against unauthorized access and inappropriate use of your electronic signatures, in any manner, by anyone other than the designated person to whom they are assigned. It should be unique to the person and not reassigned or reused by anyone else. In addition, measures should be taken to protect the links between electronic health information and signatures that prevent unauthorized modification by deletion, copying or transmission. The following instructions will help you determine if the signature requirements have been met. The Supplementary Documentation Requirement (ADR) requires a protocol or signature certificate for applications selected for medical examination. MR encourages all suppliers to carefully review all documents submitted for an ADR to ensure that all orders and services are properly signed.

Early ADR submissions that include a signature protocol or certificate for claims with illegible signatures expedite the processing of applications. If a certification requirement is required, Noridian`s timeline to complete the review will increase from 30 days to 45 days. Sample Certificate Statement: A Certificate Statement can be submitted to authenticate an illegible or missing signature on medical records. To be considered valid for Medicare medical audit purposes, your certificate must include the following: To avoid unnecessary refusals of payment, rejections, or overpayment situations, we strongly recommend that vendors check with their technical staff or software vendors to see if their current record-keeping and signing processes comply with CMS instructions. Software and hardware must meet or exceed industry standards so as not to compromise the integrity of documentation and signatures. Resources For a signature to be valid, the following criteria are used: If your institution does not currently have a signature protocol, MR accepts all submitted signature protocols, regardless of the creation date. Although creating the log can be time-consuming, the end result will be that claims with illegible signatures will be processed faster than those without a signature log. “I, (full physician/practitioner name printed), hereby certify that the medical record entry for (delivery date) accurately reflects the signatures/notes I made in my capacity as (insert provider credentials, e.g., M.D.) during the treatment/diagnosis of the Medicare beneficiary listed above. I hereby certify that such information is true, accurate and complete to the best of my knowledge and belief, and I understand that any falsification, omission or concealment of material facts may give rise to administrative, civil or criminal liability.

If a clinical diagnostic test order does not require a signature, the regulation requires the treating physician to provide medical documentation (e.g., a milestone note) indicating that they intended to conduct the clinical diagnostic trial. This must also be certified by the author by means of a handwritten or electronic signature. CMS guidelines require signatures for medical verification purposes. However, records of procedures billed to Medicare may be subject to review not only by Palmetto GBA, but also by other CMS contractors. For this reason, we inform you of the importance of these signature requirements, and if changes are necessary, we recommend that you take immediate action. Signature Requirements Medicare requires that services provided/ordered be authenticated by the author. The signature of each entry must be legible and include the practitioner`s first and last name. For clarity, we recommend that you provide your relevant references (for example, P.A., D.O. or M.D.).

The purpose of a physician`s signature in a physician`s medical records, surgical reports, prescriptions, test results, etc. in patient records, operational reports, orders, test results, etc. is to demonstrate that the services submitted to Medicare have been accurately and completely documented, verified, and authenticated. In addition, it confirms that the provider has certified the medical necessity and suitability of the service(s) subject to the Medicare program for payment. Exceptions to the above requirements Exception 1: Facsimiles of original written or electronic signatures are acceptable for certificates of incurable diseases for hospices. Exception 2: In certain circumstances, it is not necessary to sign an order. For example, orders for some clinical diagnostic tests do not need to be signed. The rules of 42 CFR 410 and Pub.100-02 Chapter 15, ยง80.6.1 state that if the order of the clinical diagnostic test is not signed, the medical documentation (e.g., a progress note) from the attending physician stating that the clinical diagnostic test should be performed. This documentation, which indicates the intention that the test will be carried out, must be authenticated by the author by a handwritten or electronic signature. Exception 3: Other CMS provisions and instructions on payment terms in relation to signatures (e.g.

punctuality standards for certain services) prevail. For medical verification purposes, if the relevant regulations, CLD, LCD and CMS manuals do not indicate whether the signature must be legible or present and the signature is illegible/missing, the examiner must follow the instructions listed below to identify the identity and credentials (e.g., MD, RN, etc.) of the signatory. In cases where relevant regulations, NCD, LCD, and CMS manuals contain specific signature requirements, those signature requirements prevail.