Recent Comprehensive Error Rate Testing (CERT) findings show an increase in denials and recoupment due to the lack of a legible identifier for services provided and/or ordered in medical record documentation review. NAS is therefore reprinting information for the NAS provider community. The emphasis of this information is to educate providers on the necessity of having legible and complete provider signatures affixed to medical documentation. Without proper signatures, the documentation is considered invalid and cannot be used to support payment for services rendered and orders given.
There are times when providers will be contacted by claim review contractors (e.g. the CERT) regarding documentation signature (or lack of it, or legibility) and will be asked to send a signed attestation for documentation the providers have submitted for review.
In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and the date of service for which the documentation pertains to.