CERT: Signature Requirements Clarification

Because recent Comprehensive Error Rate Testing (CERT) findings show an increase in denials and recoupments due to the lack of a legible identifier for services provided and/or ordered in medical record documentation review, Noridian Administrative Services is reprinting this information for providers. Without proper signatures, the documentation is considered invalid and cannot be used to support payment for services rendered and orders given.

Signature’s Purpose: Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include applicable credentials, e.g., M.D, D.O., P.A, etc.

Medicare Requirements for Valid Signatures: Acceptable methods of signing records/test orders and findings include:

• Handwritten signatures
• Electronic signatures

Unacceptable Signatures

• Signature “stamps” alone in medical records are NO longer recognized as valid authentication for Medicare signature purposes.
• Reports or any records that are dictated and/or transcribed, but do not include valid signatures “finalizing and approving” the documents are not acceptable for reimbursement purposes.
• Indications that a document has been, “Signed but not read” are not acceptable as part of the medical record.

For reference and exceptions, please refer to the Internet Only Manual (IOM) Publication 100-08, Chapter 3, Section 3.4.1.1:

“B. Signature Requirements: Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

Source: https://www.noridianmedicare.com