NGS Medicare – Increased Signature Requirement Errors

National Government Services has seen a rise in CERT errors related to "signature requirements" not being met. Providers are failing to sign orders, certification/recertification forms, and office visit notes.

Medicare mandates that all services provided, ordered, or certified be validated by the responsible individuals in accordance with Medicare’s guidelines. A signature from the treating physician or non-physician practitioner (NPP) on a note confirms that the physician or NPP agrees the note accurately reflects the care given. Reviewers are tasked with verifying that the treating physician or NPP has signed and dated the note. Acceptable signatures must be either handwritten or electronic; stamped signatures are not allowed.

The following conditions indicate signature requirements have been met:

• Clear, full signature

• Clear first initial and last name

• Illegible signature next to a typed or printed name

• Illegible signature where the letterhead or addressograph on the page identifies the signer

• Illegible signature not next to a typed/printed name, but accompanied by a signature log or attestation

• Initials next to a typed or printed name

• Initials not next to a typed/printed name, but supported by a signature log or attestation

• Unsigned handwritten note with other signed entries in the same handwriting on the same pag

Handwritten Signature: A handwritten signature is a personal mark or sign used to indicate knowledge, approval, acceptance, or obligation.

Signature Log: The typed or printed name of the author, paired with initials or an illegible signature, should include the provider's credentials and be part of the medical record.

 

Signature Attestation Statement: For Medicare medical reviews, an attestation statement must be signed and dated by the author of the entry, containing enough detail to identify the beneficiary.

 

Electronic Signature: The author’s electronic signature, including full name, credentials, date, and time of signature.

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Find Medicare signature guidance at Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)