Comprehensive Error Rate Testing – Missing or Illegible Signatures

There has been an increase of CERT errors for missing or illegible identifier on the medical records submitted to the CERT contractors. This requirement is indicated in the CMS Internet Only Manual (IOM), Publication 100-08, Chapter 3, Subsection 3.4.1.1.B which notes Medicare contractors require 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.

Electronic or handwritten signature shall be accepted as the identifier for the provider rendering the service. Documentation submitted without the above will receive an error and the Medicare claim will be adjusted to reflect the CERT error.

National Government Services encourages physicians to verify that a legible signature is present on all medical records during their quality check before the document is filed in the patient’s permanent record.

For illegible signatures the CERT contractor will accept a signature key, a signature page or documentation affirming the provider indeed signed the medical records. National Government Services recommends one of the signature documents to be submitted routinely with the CERT request to prevent the claim from being denied for illegible signature because of the provider’s unique writing style.

A signature key or signature page should include the provider’s typed name, original signature and initials. The difference between the two is the signature key should include every provider’s signature and initials within the group while the signature page would only include one provider’s signature and initials.

The signature document being submitted routinely with the medical records will be used to help identify the signature of the performing/ordering provider during the review of the medical records. This will help prevent CERT errors and Medicare claims adjustments.