Coding & Reimbursement

CMS scrutinizes signatures

By Suzanne L. Corcoran, COE

Medicare auditors continue to find areas of weakness in medical charts. The most recent area of scrutiny is missing or inappropriate physician signatures.

Q. Does Medicare look at provider signatures during a review?

A. CMS Transmittal 327, dated March 16, 2010, updates the Program Integrity Manual §3.4.1.1 for signature requirements. It states: "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable… A handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation." There are a number of acceptable signature options:

• Legible full signature
• Legible first initial and last name
• Initials over a typed or printed name
• Illegible signature over a typed or printed name
• Illegible signature where other information on the page indicates the identity of the signator (e.g., letterhead with providers' names printed and one is circled).

In the absence of an acceptable signature, other satisfactory alternatives include:

• A signature log on file
• An attestation statement per chart entry
• Unsigned note where other entries on the same page in the same handwriting are signed.

Q. What is a signature log?

A. A signature log is a file for the practice or group that contains the typed or legibly printed name of each provider together with the associated illegible signature(s) in the chart. Physicians and other providers are encouraged (but not required) to include their credentials in the log (i.e., MD, DO, OD, PA).

Fortunately, reviewers have been instructed to consider signature logs without regard to the creation date, so you may create a log at any time and apply it to documents created at an earlier date.

Q. What is an attestation statement?

A. An attestation statement substantiates that the entry in the medical record was made by the particular provider whose signature is either missing or does not meet signature requirements. The statement must contain adequate information to identify the beneficiary, the date of service and the full name of the provider. A sample attestation statement is included in Transmittal 327, although CMS does not require a specific format or form.

Q. Do I need to confirm the signatures of ancillary staff in the medical record or signature log?

A. No. Reviewers seek to validate that the provider's mark or sign exists, signifying approval, acceptance or obligation of the information in the medical record. For the purposes of claims, signatures of ancillary staff, including registered nurses, licensed practical nurses, or technicians (including COA, COT, COMT) are not subject to audit. However, you may wish to identify signatures of these ancillary staff for internal reasons and may include them in the log if you wish.

Q. What if I use an electronic signature?

A. The CMS transmittal encourages physicians to check with their attorneys and malpractice insurers concerning the use of alternative signature methods including electronic signatures. The primary concern is the potential for misuse or abuse. Systems must be protected against the ability to forge, falsify or "modify" a signature. The responsibility for authenticity of the electronic signature remains with the provider.

Q. Which documents require a signature?

A. All documents that are part of the medical record require a signature. For example, office visits, consultation reports, interpretation of diagnostic tests, operative reports and prescriptions require a signature. This list is not exhaustive and we are not aware of any comprehensive official list. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.