Medicare Requirements for Valid Signatures

This article is being written to notify providers of an increase in Comprehensive Error Rate Testing (CERT) denials due to the lack of a legible identifier for the services provided and/or ordered in medical record documentation review. Ensuring that all services are ordered, legible and medical necessity is supported in the medical records will decrease your facility’s recovery of services that were billed to Medicare and reviewed by the CERT contractor.

CERT Error – Medically Unnecessary Service/Treatment (25)

• IssueThe CERT contractor receives medical documentation that includes an order or a requisition for diagnostic laboratory services and test results yet the signature was not legible.

  RecommendationMedicare requires that the individual who orders services/treatment be clearly identified in the medical records. The recommended format for each entry is to include the practitioner’s first and last name, including the applicable credentials, e.g. MD, DO, PA etc.

• IssueThe CERT contractor receives a progress note that is dictated without any indication that the medical documentation is from the ordering physician.

  RecommendationThe physician intent cannot be determined so the services are not medically necessary and do not support payment. Medicare requires documentation of all services rendered in order for a claim to be properly evaluated. In order to support physician intent, all medical documentation must be complete; including the specific tests to be ordered, legible, and authenticated by the ordering physician.

Source: https://www.noridianmedicare.com