CERT Review Process Strictly Enforcing Rule Requires Legible Signature on all Clinic Notes, Orders and Other Documentation

The CERT review process is now strictly enforcing a long standing rule that requires a legible signature on all clinic notes, orders and other documentation (e.g. procedure notes) used to substantiate a claim billed to Medicare. Section 1833(e) of the Social Security Act states that contractors must be able to identify the provider who performed the service in order to pay. CMS defines a legible signature or electronic signature as the appropriate ways of identification.

Failure to have a written or electronic signature on these items will result in a denial regardless of the medical necessity.

All Medicare providers billing Medicare for service shall ensure that their signature is attached to these documents. Each provider should immediately put into place a protocol to assure these items are signed within a reasonable time frame, usually 48-72 hours after the encounter but certainly before the claim is submitted.

If a physician written signature is not legible, and many are not, please include a signature sheet with any submissions to the CERT carrier or the RAC carrier. This sheet should include the physician’s written signature and his/her legible printed or typed name. If others have made entries on the items submitted it is recommended that they be included ion this signature sheet. Scrawled illegible initials will not suffice, but clear, legible initials accompanying a typed or printed name will usually be acceptable with the initials noted on the signature sheet.

Electronic signatures should clearly show that the item has been electronically signed and include a date and if possible a time.

Source: https://www.cgsmedicare.com/