Medicare Providers: What You Need to Know About Signatures and Documentation

From the Desks of the Palmetto GBA Medical Directors

Palmetto GBA frequently encounters errors assessed by the Comprehensive Error Rate Testing (CERT) Review contractor due to signature problems on submitted medical records, X-ray reports and laboratory or radiology orders. As Medicare providers, you may be asking what significance this has for you. The discovery of CERT errors may lead to increased scrutiny of future services that you bill to Medicare. Your understanding of this important issue is essential to ensuring the accuracy of your Medicare claims.

Palmetto GBA strives to communicate with the Medicare physician community, compliance officers, Provider Outreach and Education Advisory Groups, Contractor Advisory Committee members, hospital administrators, and others. We feel it is critical to share this information with you.

We believe that a reduction in signature errors/problems can be accomplished through timely and thorough provider education. We want you to know what is needed to resolve these issues. By fully understanding documentation requirements, you can improve your accuracy with claims submissions.

The Centers for Medicare & Medicaid Services (CMS) requires that services provided or ordered be authenticated by the author. Palmetto GBA has examined numerous examples of CERT signature denials and found in almost every instance, the basic documentation was acceptable. However, these services were denied due to one of the following unacceptable signature reasons: 

• Illegible, unrecognizable handwritten signatures or initials
• Transcribed or typed progress notes with a typed name only and no written or electronically validated signature
• Unverified or unauthorized electronic signatures
• Lack of any indication of the rendering physician/practitioner

Palmetto GBA values your time and respects the many challenges physicians and health care providers face as they provide needed medical services to our aged and disabled population. However, the obligation to submit medical record documentation with valid signatures cannot be avoided. Valid signatures allow for verification that provided services have been accurately and fully documented, reviewed and authenticated. A valid signature also confirms that the provider is certifying the provided item or service was medically reasonable and necessary which in turn allows consideration for timely and appropriate payments.

Important Elements to Remember

• If a signature has legibility issues, a signature log or an attestation statement needs to accompany the claim
• Electronically signed records must have digitized signatures (electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet) or electronic signatures with date and timestamps that include verbiage such as “electronically signed by,” “verified by,” “reviewed by” or “authenticated by.” We strongly recommend professional designation/credentials as coverage for many services is provider specialty dependent. Without credentials, payment may be unnecessarily delayed and/or coverage denied. Operational processes and/or work with your technical staff or software vendors may be needed to ensure valid signatures, per CMS instructions, are affixed to every order, record or report within a reasonable time frame. This would customarily be expected within 48 to 72 hours after the encounter and certainly before the claim is submitted to Medicare for payment consideration.
• Digital signatures are typically generated by special encrypted software that allows for sole usage
• Signature stamps are not allowable as valid authentication for Medicare purposes (an exception would apply for a physically disabled author who can provide proof of inability to sign due to disability)
• Reports or records that are dictated and/or transcribed without valid signatures are not acceptable for reimbursement. A typed name is not a valid signature.
• “Auto-authentication” or “auto-signature” systems that do not mandate or permit the provider to review an entry before signing are strongly discouraged. Any indication that a document has been signed but not read is not acceptable.
• Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic signature by anyone other than the designated individual to whom it is assigned. It 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 to ensure there is no possibility of unapproved alteration. 
• We encourage you to share this information in support of our efforts to ensure that claims and supporting documentation are properly indicated on claims submissions or redetermination requests. For a more expansive list of acceptable and unacceptable examples please see the Palmetto GBA article "Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices." Additional information about the CERT program is available on our website under the CERT link.

Sincerely,

Lisa Banker, MD, FACP, CCDS, CCS