Actual physician signature on medical record

Written by Reed Tinsley, CPA | October 15, 2008

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 3.4.1.1B www.cms.hhs.gov/manuals/downloads/pim83c03.pdf

Change Request 5791

www.cms.hhs.gov/Transmittals/downloads/R248PI.pdf

Medicare Learning Network (MLN), MM5791

www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdf

Change Request 6100

http://www.cms.hhs.gov/transmittals/downloads/R94BP.pdf

 

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.

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