Medical record signature requirements
All medical records, chart notes, procedures and orders submitted for review must be dated and 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 22.214.171.124.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 126.96.36.199.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
The individual who ordered and/or provided services must 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.)
Provide a signature log with any review of medical records so Priority Health can easily verify a provider's signature or initials.
Go to signature log requirements.
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 08:44 am
- Signature "stamps"
- Missing signature on dictated and/or transcribed documentation
- "Signed but not read" indicators
- Illegible lines or marks
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.
Priority Health will permit use of an attestation form when a signature is missing due to an inadvertent omission. The attestation is used to identify the provider of service and authenticate that medical record information is accurate and complete.
Inappropriate use of attestation
Although the attestation will be accepted regardless of the date it was created, it should not be utilized to "backdate" services relating to orders, plan of care, etc.
We require that a record be signed to be considered for medical review. Priority Health may report a provider for potential fraud if a provider is frequently/regularly using the attestation process rather than to correct the occasional inadvertently missing signature.
In order to be considered valid for Priority Health documentation review purposes, an attestation statement must:
- Be signed and dated by the author of the medical record entry. Attestation statements will not be accepted if signed by someone other than the author of the medical record.
- Clearly identify the Priority Health member receiving treatment or services.
Priority Health suggests the following CMS-approved wording for an attestation:
"I, ___ [print full name of the physician/practitioner] __, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as ___ [insert provider credentials, e.g., M.D.] __ when I treated/diagnosed the above listed Priority Health member. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability."
- Reference: CMS Medicare Program Integrity Manual, section 188.8.131.52.D.1.b (see page 22 of this PDF document)
The attestation statement should be submitted with:
- Priority Health Appeal form (Appeal I or II form depending on where provider is in process of appeals)
- Copy of medical records (if not already submitted)
- Explanation of why the signature was omitted from original medical record
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