If it is not Signed, then it is not Complete

Is your documentation signed and ready for a medical record review?

Prior to submitting records to Medicare, you must ensure that the documentation is signed. For medical review purposes, Medicare requires that services provided and/or ordered are authenticated by the author. The signature must be handwritten or electronic. There are several variations of acceptable handwritten and electronic signatures that are available to providers. A claim without a valid signature runs the risk of being denied for payment.

Did you know an illegible signature or provider’s initials are permitted? The signature or initials must be directly above a typed or printed name. A signature log that matches the signature on the documentation can also be submitted with medical records.

If there is no signature or the signature is illegible, there is still another option. A signature attestation can also be used if the attestation statement is signed and dated by the author of the medical record entry and contains sufficient information to identify the beneficiary.

Note: You should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead make use of the signature authentication process.

Remember, if it’s not signed, it’s not complete.

For full guidelines, exceptions and examples of acceptable signatures please see the following references.

Medicare Program Integrity Manual, Publication 100-8, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, Subsection – Signature Requirements

Medicare Learning Network, MLN Matters: MM6698

Source: Novitas

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