Guidance for Provider Signature Requirements

WPS Medicare continues to see Comprehensive Error Rate Testing (CERT) errors assessed for illegible or missing provider signatures in medical record documentation. Medicare requires that services provided/ordered be authenticated by the author. The method used shall be hand written or an electronic signature. Stamped signatures are not acceptable. Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead may make use of a signature attestation statement confirming they performed the service.

For more detailed guidelines on specific signature related topics, select one of the links below, or scroll to read the full article.

Dictated Notes and Use of Initials
Electronic Medical Records (EMR)
Physician Orders
Signature Logs or Cards
Attestation Statements

Dictated Notes and Use of Initials

  • The physician must review the transcribed note to correct any errors and affirm the note's contents for it to be considered the final documentation of the service
  • It is not sufficient that the provider is designated as dictating the note or his/her name is present in the record
  • If an illegible handwritten signature is present and the record contains no other identification of the author (i.e., printed name below, or letterhead with name) a signature log or attestation statement must be included with your response to the documentation request
  • If the record is missing a signature, an attestation statement must be included in your response to the documentation request
  • A legible signature that includes the provider's full name and credentials is always the best practice
  • Initials are acceptable if signed over a typed or printed name
  • Without a typed name to identify the author, a signature log or attestation statement must be submitted or services may be denied

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Electronic Medical Records (EMR)

For providers using EMR systems, it is crucial that the electronic signature is affixed to the records when responding to all Medicare requests for documentation. Although CMS has not published formal regulations regarding electronic signatures, we recommend that an electronic signature be accompanied by a statement indicating that the signature was applied electronically. We also recommend including the date and time the record was authenticated. Electronic signature notations can include the following (not all-inclusive):

  • 'Electronically signed by'
  • 'Verified by'
  • 'Reviewed by'
  • 'Released by'
  • 'Signed by'
  • 'Authenticated by'
  • 'Authorized'
  • 'Confirmed by'
  • 'Finalized by'
  • 'Electronically approved by'

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Physician Orders

  • Medicare will disregard an unsigned order during the review of the claim. An attestation statement is not acceptable for an unsigned physician order. To meet Medicare signature requirements:
    • Documentation (i.e., a progress note) must be submitted which clearly indicates the intent that the specific service(s) be provided
    • If the progress note supporting intent does not contain a valid provider signature, an attestation statement should also be submitted in response to the record request
  • For more information on physician order requirements refer to CMS Internet-Only Manual, Publication 100-02, Chapter 15, Section 80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests at https://www.cms.gov/manuals/Downloads/bp102c15.pdfAdobe Portable Document Format

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Signature Logs or Cards

If the medical record contains an illegible signature, providers should include a signature log in their submitted documentation, listing the typed or printed name of the author associated with the initials or illegible signature. The signature log can be included on the actual page with the initials or illegible signature, or can be a separate document.

Please remember that since a provider's signature may change over time, signature cards or logs should be kept current. CERT may assess errors for signature cards with signatures that no longer match the signature on medical record documentation.

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Attestation Statements

An attestation statement can be used in cases of illegible or missing provider signatures (excluding physician orders). 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. An attestation example can be found on WPS Medicare's Forms page, under Other Forms.

It is crucial that medical record documentation be complete and legible, and be authenticated and dated promptly by the practitioner who is responsible for ordering, providing or evaluating the service(s) rendered. The lack of these elements in your documentation may result in claim denials upon review.

You can find complete signature requirement regulations in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Publication 100-08, Chapter 3, Section 3.3.2.4 at https://www.cms.gov/manuals/downloads/pim83c03.pdfAdobe Portable Document Format

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Page Last Updated: Monday, 02-Apr-2012 11:50:47 CDT