Signature requirements clarification

First Coast Service Options Inc. (FCSO) has seen a significant increase in the number of CERT errors related to the lack of a legible signature in medical record documentation. The CERT contractor confirmed that CMS and the OIG have clarified that providers of Medicare services must comply with the signature legibility requirements outlined in the Internet-only manual, Publication 100-08, Chapter 3, Section 3.4.1.1 B:

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. (The only exception is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.)

The legible identifier (signature) requirement applies to documentation for any service performed and billed to Medicare. The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to support that the services have been accurately and completely documented, reviewed and authenticated.

The CERT contractor is rigorously enforcing the CMS requirement that all medical records subject to medical review must include a legible identifier (signature). Documentation that is submitted with an illegible signature, initials, an unauthenticated electronic signature, no signature, or an unsigned typewritten signature will be denied and assigned a CERT error. This error will produce an overpayment and a subsequent recoupment of funds.

Physicians, non-physician practitioners, and other health care providers who bill Medicare contractors must remember:

• A legible signature is required on all medical records subject to medical review.
• Prior to submission for medical review, every medical record should be audited to ensure that the beneficiary’s name, the date of service, and the signature of the provider of services are on the records.
• If the provider’s signature is illegible, a signature legend/log identifying the author associated with the illegible signature or initials should be submitted with the records. This applies to records submitted to any Medicare contractor, including the Medicare Administrative Contractor (MAC) and the CERT contractor.
• Electronic signatures should be safeguarded against misuse (such as password protected) and should be easily identifiable as electronic, rather than typewritten, signatures.