Oct 15

Actual physician signature on medical record

Yesterday I received the following question:

Can you tell me what CMS or Medicare has mandated on physician's signatures in the physician's office for medical records.  We thought that in the physician's office that it was not mandated to-date that the record need to be signed.  We thought that as long as the doctor's name was clearly identifiable, that to-date it was not mandatory by CMS (medicare).

A colleague friend of mine, David Zetter (djzetter@cavmich.com) had this response from the NSCHBC listserv:

No signature = no credit = no reimbursement.  If there is not a signature, there is no proof the provider agrees with the documentation that was written or transcribed.

Signature is required electronically or handwritten.  Nothing else will be paid by Medicare.  A colleague of mine in Pennsylvania just had a meeting with Provider Education in Harrisburg and validated this due to various communications coming from Conditions of Participation and Change Request 6100 which was recently issued.

David provided the following supporting documentation:

CMS Pub. 100-8, Chapter 3, Section www.cms.hhs.gov/manuals/downloads/pim83c03.pdf

Change Request 5791


Medicare Learning Network (MLN), MM5791


Change Request 6100


About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →