Medicare signature requirements

509
Jurisdiction 1 Part B
Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable
Practices
CMS guidelines mandate the presence of signatures specifically for all "medical review purposes, modifiers,
etc., records pertaining to any procedures billed to Medicare Part B. Please share with your staff the
signature requirement changes for incident to, split/shared services and co-surgeon or assistant-at-surgery
services.
Applies to:
Jurisdiction 1//J1 Part B: General
While CMS guidelines mandate the presence of signatures specifically for all 'medical review' purposes,
modifiers, etc., records pertaining to any procedures billed to Medicare Part B are potentially subject to
review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the
importance of these signature requirements and if changes are needed, we suggest you take immediate
action.
The contents of this article are applicable to every Medicare claim processed by or medical record submitted
to Palmetto GBA on or after April 28, 2008, (for dates of service on or after September 3, 2007). These
instructions do not address CMS documentation requirements for specific situations.
Signature's Purpose
Medicare requires the individual who ordered/provided services be clearly identified in the medical records.
The signature for each entry must be legible and should include the practitioner's first and last name. For
clarification purposes, we recommend you include your applicable credentials, e.g., P.A., D.O., or M.D.
The purpose of a rendering/treating/ordering practitioner's signature in patients' medical records, operative
reports, orders, test findings, etc., is to demonstrate the Part B services have been accurately and
fully documented, reviewed and authenticated. Furthermore, it confirms the provider has certified the
medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment
consideration.
Medicare Requirements for VaIid Signatures
Acceptable methods of signing records/test orders and findings include:
Handwritten signatures or initiaIs
EIectronic signatures:
R Digitized signature - an electronic image of an individual's handwritten signature
reproduced in its identical form using a pen tablet
R EIectronic signatures usually contain date and timestamps and include printed statements,
e.g., 'electronically signed by,' or 'verified/reviewed by,' followed by the practitioner's name
and preferably a professional designation. Note: The responsibility and authorship related to
the signature should be clearly defined in the record
R DigitaI signature - an electronic method of a written signature that is typically generated by
special encrypted software that allows for sole usage
Note: Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-
signature' systems, some of which do not mandate or permit the provider to review an entry before signing.
ndications that a document has been, 'Signed but not read' are not acceptable as part of the medical record.
AcceptabIe Signature ExampIes
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 compute.
'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

UnacceptabIe Signatures
Signature 'stamps' alone in medical records are no longer recognized as valid authentication for
Medicare signature purposes and may result in payment denials by Medicare
Reports or any records that are dictated and/or transcribed, but do not include valid
signatures 'finalizing and approving' the documents are not acceptable for reimbursement purposes.
Corresponding claims for these services will be denied.
See unacceptabIe signature exampIes:
R 'Signing physician' when provider's name is typed
Example: Signing physician: ______________________
John Smith, M.D.
R 'Confirmed by' when a provider's name is typed
Example: Confirmed by: ______________________
John Smith, M.D.
R 'Signed by' followed by provider's name typed and the signing line above, but done as part
as the transcription.
R 'This document has been electronically signed in the surgery department' with no provider
name.
R 'Dictated by' when provider's name is typed
Example: Dictated by: ______________________
John Smith, M.D.
R Signature stamp
R 'Signature On File'
Question: What if can't get a handwritten or electronic signature because the provider is deceased or has
left the practice?
Answer: f the provider is in a group practice, another provider within the group may sign on his/her behalf;
however the following information must be provided:
The submitting provider, John W. Smith, M.D., is unable to sign this medical record because he
expired on 10/08/08.
or
John W. Smith, M.D. relocated to Colorado on 10/08/08 and was unable to sign this medical record.
Unique Signature Situations:
Incident to: ncident to a physician's professional services means that the services or supplies
are furnished as an integral, although incidental, part of the physician's personaI professionaI
services in the course of diagnosis or treatment of an injury or illness. Only the Past, Family, and
Social History (PFSH) and Review of Systems (ROS) may be documented by ancillary personnel
incident to and incorporated in to the E/M documentation, which must be reviewed and signed by
the biIIing provider.
Services of nonphysician practitioners ordinarily performed by the physician such as minor surgery,
setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or
treatment of a patient's condition are also covered as services incident to a physician's professional
services. f the NPP performs an entire service incident-to the physician (office/clinic/home settings
only), the medical record may be signed by the NPP or the physician.
SpIit/shared services:
R Office setting: When an E/M service in an office setting is a shared/spIit encounter
between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is
considered to have been performed "incident to" if the requirements for "incident to are
met and the patient is an established patient. The service is reported using the physician's
billing number. The physician must sign.
f "incident to requirements are not met for the shared/split E/M service, the service must
be billed under the NPP's billing number, and payment will be made at the appropriate
physician fee schedule payment. The biIIing NPP provider must sign.
R HospitaI-based setting: When a hospital inpatient/hospital outpatient or emergency
department E/M is shared between a physician and an NPP from the same group practice
and the physician provides any face-to-face portion of the E/M encounter with the patient,
the service may be billed under either the physician's or the NPP's number. However, if
there was no face-to-face encounter between the patient and the physician (e.g., even if
the physician participated in the service by only reviewing the patient's medical record)
then the service may only be billed under the NPP's number. Payment will be made at the
appropriate physician fee schedule rate based on the billing number entered on the claim.
The biIIing provider (physician or NPP) as determined above must sign.
Assistant at surgery: t is not required that a surgical assistant also sign the operative report in
addition to the responsible surgeon when reference is made in the note that identifies the assistant,
provided that the report contains an acceptable signature by the responsible surgeon
Regarding Co-Surgeons: The co-surgeon must follow the signature requirements and provide an
acceptable signature
Scribes: The signature of the scribe is not required. The scribe's name needs to be listed in the
medical record and identified as a scribe. The signature requirements for the billing provider still
apply.
EIectronic MedicaI Records: Recommendations
The electronic system you select should include a process that verifies the individual signing their name has
reviewed the contents of the entry and determined it contains what they intended.
Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic
signatures, by whatever method, by anyone other than the designated individual to whom it is assigned.
t is to be unique to him/her, and not reassigned nor reused by someone else. Furthermore, measures
should be in place to protect the "links between electronic health information and signatures which prevent
unapproved alteration through removal, copying or transfer.
To avoid unnecessary payment denials, rejections or overpayment situations, we strongly urge providers
to check with their technical staff or software vendors to verify their current record-keeping and signature
processes are in compliance with CMS instructions. Software/hardware should meet or exceed industry
standards to avoid compromising the integrity of documentation and signatures.
For reference and exceptions, please refer to the Medicare Program ntegrity Manual, Pub. 100-08, Chapter
3, Section 3.4.1.1 B and MLN Matters article # MM 5971. They are accessible through the following two
links:
www.cms.hhs.gov/manuals/downloads/pim83c03.pdf (PDF, 643 KB)
www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdf (PDF, 62 KB)
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H:medorg: medicare resources: Medicare signature requirements 509 from Palmetto GBA J1
Other links: http://www.cgsmedicare.com/parta/pubs/news/2012/0212/264.html