Signature Requirements
Medicare requires a legible identifier for services provided/ordered. The
method used must be handwritten or an electronic signature (stamped signatures
are not acceptable) to sign an order or other medical record documentation for
medical review purposes.
Exception: Facsimile of original written or electronic signatures is acceptable
for the certifications of terminal illness for hospice.
Providers using electronic systems should recognize that there is a potential
for misuse or abuse with alternate signature methods. Facsimile and hard copies
of a physician’s electronic signature must be in the patient’s medical record
for the certification of terminal illness for hospice. For example, providers
need a system and software products that are protected against modification,
etc., and should apply administrative procedures that are adequate and
correspond to recognized standards and laws. The individual whose name is on
the alternate signature method and the provider bear the responsibility for the
authenticity of the information being attested. Physicians should check with
their attorneys and malpractice insurers regarding the use of alternative
signature methods.
All state licensure and state practice regulations continue to apply. Where
state law is more restrictive than Medicare, the state law standard will apply.
The signature requirements described here do not assure compliance with
Medicare conditions of participation.
Acceptable and Unacceptable Documentation Signatures
As a reminder, the treating physician’s signature must be present in the
documentation associated with all services submitted to Medicare. Medicare
requires the signature be a legible identifier for the provided/ordered
services.
The physician’s signature can be in the form of either a handwritten signature
or an electronic signature. Stamped signatures (i.e., rubber stamps) are not
acceptable signatures.
The following list provides examples of acceptable electronic signatures:
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 computer.·
“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.·
Examples of acceptable handwritten signatures:
The handwritten signature must be
legible.·
The handwritten signature must clearly
identify the provider performing the billed services.·
Examples of unacceptable signatures:
The legible signature is missing from
the documentation.·
The signature is illegible.·
The signature cannot be verified as that
of the performing provider.·
The signature is typewritten but not
authenticated by either a handwritten·
signature or an electronic signature.
The provider’s letterhead does not
constitute legible identification.·
The provider’s initials do not
constitute legible identification.·
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