APR 06, 2016
CERT On the Lookout For Missing Signatures
Missing or illegible signatures continue to be a problem according to Comprehensive Error Rate Testing (CERT) contractor. CERT audits Medicare Part B by auditing your records. If a signature is missing or unable to be read, the reviewer may move to recoup funds immediately. Handwritten or electronic signatures must be included on exams and procedures, as well as any ordered testing or laboratory services. Stamped signatures are no longer acceptable.
Practices with paper charts should create a signature log of anyone who may document in the chart, including front desk or billing staff, and always send this log along for charts that are requested.
Electronic signatures are acceptable for those who have an EHR system. It is recommended by many Medicare Contractors to include such language as “Electronically signed by” or “Authenticated by” as this indicates to any reviewer the record as been electronically signed.
If a record is found by a physician to have a missing or illegible signature, it is recommended to provide an attestation statement indicating validity of the documentation. The author of the records needs to provide a signature and date, as well as the beneficiary information, in order for Medicare to consider this a valid authentication. The Attestation statement can be stated as “I (print full name of physician), 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 Medicare beneficiary. 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.”
For additional information view MLN matters article, "Signature Guidelines for Medical Review Purposes".