Auditors of recent chart reviews have reported an increase in the number of records reviewed that have unacceptable signatures.
Medicare contractors require a legible identifier for services provided or ordered. The signature may be handwritten or an electronic signature may be used. Stamped signatures are not acceptable to sign an order or any other part of the medical record. CMS has clarified that acceptable methods of signing records and/or tests include:
1. Legible handwritten signatures or initials.
If initials are used, they must be legible and the reviewer must be able to determine whose initials are used.
2. Electronic signatures
- Digitized signature: an electronic image of an individual's handwritten signature reproduced in its identical form using a pen tablet. Note: This is an "actual," real-time signature done electronically, like the digital sign-out with a credit card transaction.
- Electronic signatures usually contain date and timestamps and include printed statements, e.g., “electronically signed by” or “verified/reviewed by,” followed by the practitioner's name and, preferably, a professional designation. Note: The responsibility and authorship related to the signature should be clearly defined in the record.
- Digital signature: an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage.
: Be aware that electronic and digital signatures are not the same as “auto-authentication” or “auto-signature” systems, some of which do not mandate or permit the provider to review an entry before signing. Indications that a document has been “signed but not read” are not acceptable as part of the medical record. Remember, these rules apply even when the ophthalmologist is the only person writing in the chart.
Ideally, the signature will contain the rendering provider's first and last names and credentials (MD, DO, NP, PA, etc.,) and the date of the service. Stamped signatures, scrawled initials or illegible signatures do not constitute valid, "legible signatures" and may subject a claim to denial upon review.
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About the author: This article was written by AAOE coding executive Sue Vicchrilli, COT, OCS. It originally appeared in the May 2009 Coding Bulletin.