Medicare requires that services provided to a patient are authenticated in the patient health record. Hand written or electronic signatures are acceptable. A handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation. Signature must comply with the following:
* Stamp signatures are not acceptable.
* You must be familiar with your Local Coverage Determination (LCD) policy on authenticating records as these policies will take precedence over the guidelines below.
* If, in the course of a patient health record review, a signature is found to be illegible, Medicare contractors will look for a signature log or attestation statement to determine the identity of the provider.
* A signature log includes a list of the typed or printed name(s) of the author(s) of the associated initials or illegible signature(s).
* The signature log can be included on the page where the initials or signature are present, or may be in a separate document.
* Although a reviewer may encourage providers to list their credentials in the signature log, a claim should be not denied if the log is missing a provider’s credentials.
* All signature logs should be considered regardless of the date the log was created.
Attesting to a Signature’s Validity
Providers can include an attestation statement in the documentation they submit. Only the author of the medical record can attest to the record in question.
Attestations will be accepted by reviewers regardless of the date of the attestation, except in those cases where the regulations or policy indicate that a signature must be in place prior to a given event or a given date. For example, if a policy states the physician must sign the plan of care before therapy begins, an attestation can be used to clarify the identity associated with an illegible signature but cannot be used to “backdate” the plan of care.
CMS recommends that, rather than backdating a patient health record, providers should use the signature authentication process explained below. In some situations, a provider may be contacted by a contractor and asked to submit an attestation statement or signature log. Providers will have 20 calendar days from the date of the contractor’s call, or the date that the request letter is received by the post office, to provide the information. To be valid for Medicare medical review purposes, the attestation statement must be signed and dated and contain sufficient information to identify the beneficiary. An example is included below:
“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., DC]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hearby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
