Medical record signature requirements
Priority Health requires that medical records submitted for review must be signed by the rendering practitioner.
- A medical record that does not contain a valid signature may result in claim denials or recovery of overpayments.
- Signatures added to documentation following a claim denial will not be accepted.
This is modeled after requirements in the Centers for Medicare and Medicaid Services (CMS) Medicare Program Integrity Manual (MPIM). Specifically, Section 3.4.1.1.D, Chapter 3 of the MPIM states:
"For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable."
According to the CMS manual, records should be signed prior to being billed. Section 3.4.1.1.D, Chapter 3 of the MPIM also states:
"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 the signature authentication process."
While this CMS requirement does not govern commercial health plans, Priority Health has made the business decision to adopt the CMS signature requirement across all of its lines of business. This standard is recognized as a best practice by professional associations such as the American Health Information Management Association (AHIMA) and the American Academy of Family Physicians (AAFP).
Purpose of practitioner signature
Priority Health requires the individual who ordered and/or provided services be clearly identified in the medical records to:
- Indicate that the service has been accurately and fully documented, reviewed and authenticated
- Confirm that the provider acknowledges the medical necessity and reasonableness for the service(s) that were rendered
Acceptable handwritten signatures
- Appear on each entry
- Are legible
- Include the practitioner's first initial and last name
- (Recommended but not required) Include the practitioner's credentials (P.A., D.O., M.D., etc.)
Acceptable digitized/electronic signatures
- The responsibility for and authorship of the digitized or electronic signature should be clearly defined in the record.
- A "digitized signature" is an electronic image of an individual's handwritten signature. It is typically generated by encrypted software that allows for sole usage by the practitioner.
- An electronic or digitized signature requires a minimum of a date stamp (preferably includes both date and time notation) along with a printed statement such as, "Electronically signed by," or "Verified/reviewed by," followed by the practitioner's name and preferably a professional designation. An example would be: Electronically signed by: John Doe, M.D. 10/01/2011
Unacceptable signatures
- Signature "stamps"
- Missing signature on dictated and/or transcribed documentation
- "Signed but not read" indicators
- Illegible lines or marks
Attestations
Priority Health will permit the use of an attestation form when a signature has been inadvertently omitted. However, patterns or consistent use of attestation in place of signed records may lead to further investigation of claims data. This is consistent with the fraud referrals information on page 17 of CMS Pub 100-08, Medicare Program Integrity:
"At any time, evidence of fraud shall result in referral to the PSC/ZPIC for development. If AC, MAC or CERT reviewers identify a pattern of missing/illegible signatures it shall be referred to the appropriate PSC/ZPIC for further development."
Go to guidelines for attestations.
Additional references
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