Coding & Compliance - June 2010

“Signature Requirements: What is Acceptable?”

 MMMeMMedicare requires that services provided/ordered be authenticated by the author.  The signature for each entry must clearly identify at least the first initial and last name of the practitioner.  For clarification purposes, we recommend you include your applicable credentials, e.g., P.A., D.O., or M.D.

The purpose of a rendering/treating/ordering practitioner's signature in patients' medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated.  Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.

-     Listed below are examples of acceptable electronic and written signatures:

Acceptable Electronic Signature Examples

·         'Accepted by John Smith, M.D.'

·         'Authenticated by John Smith, M.D.'

·         'Authorized by John Smith, M.D.'

·         'Closed by John Smith, M.D.'

·         'Confirmed by John Smith, M.D.'

·         'Digital Signature:  John Smith, M.D.'

·         'Electronically approved by John Smith, M.D.'

·         'Electronically signed by John Smith, M.D.'

·         'Finalized by John Smith, M.D.'

·         'Released by John Smith, M.D.'

·         'Reviewed by John Smith, M.D.'

·         'Signed:  John Smith, M.D.'

·         'Signed before import by John Smith, M.D.'

·         'Signed by John Smith, M.D.'

·         'This is an electronically verified report by John Smith, M.D.'

·         'Verified by John Smith, M.D.'

·         Digitized signature: Handwritten and scanned into the computer

·         Signature Derived from Controlled Access Password

Acceptable Written Signatures Examples

·         Legible full signature

·         Legible first initial and last name

·         Illegible signature over a typed or printed name

·         Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the signatory.  Example: An illegible signature appears on a prescription.  The letterhead of the prescription lists 3 physicians’ names.  One of the names is circled.

·         Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by: 1) a signature log, or 2) an attestation statement

·         Initials over a typed or printed name

·         Initials NOT over a typed/printed name but accompanied by: 1) a signature log, or 2) an attestation statement

·          Unsigned handwritten note where other entries on the same page in the same handwriting are signed

If you have any questions or need additional information regarding this article, please contact Cindy Tipton-Cain at Cindy_Cain@MED3000.com 

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