Documentation Signatures

As a reminder, the treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires the signature be a legible identifier for the provided/ordered services.

NOTE: CMS Change Request 6100 clarifies that “ No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.”

The physician’s signature can be in the form of either a handwritten signature or an electronic signature. Stamped signatures (i.e., rubber stamps) are not acceptable signatures.

The following list provides examples of acceptable electronic signatures:

  • Chart “Accepted by” with provider's name.
  • “Electronically signed by” with provider's name.
  • “Verified by” with provider's name.
  • Reviewed by” with provider's name.
  • Released by” with provider's name.
  • Signed by” with provider's name.
  • Signed before import by” with provider's name.
  • Signed: John Smith, M.D.” with provider's name.
  • Digitalized signature: Handwritten and scanned into the computer.
  • This is an electronically verified report by John Smith, M.D.”
  • Authenticated by John Smith, M.D.”
  • Authorized by: John Smith, M.D.”
  • Digital Signature: John Smith, M.D.”
  • Confirmed by” with provider's name.
  • Closed by” with provider's name.
  • Finalized by” with provider's name.
  • Electronically approved by” with provider's name.

Examples of acceptable handwritten signatures:

  • The handwritten signature must be legible.
  • The handwritten signature must clearly identify the provider performing the billed services.

Examples of unacceptable signatures:

  • The legible signature is missing from the documentation.
  • The signature is illegible.
  • The signature cannot be verified as that of the performing provider.
  • The signature is typewritten but not authenticated by either a handwritten signature or an electronic signature.
  • The provider’s letterhead does not constitute legible identification.
  • The provider’s initials do not constitute legible identification.

Published by XIFIN

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