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Loss of Medicare Reimbursement — Missing Signatures

  • A CMS regulation (e.g. NCD, LCD or Medicare manual) that includes specific signature requirements takes precedence over the guidelines in Transmittal 327. Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead may use the signature authentication process described below.
  • Also, contractors may add language in their additional documentation requests (ADRs) directing billing providers to contact another entity to obtain the signed version of a document. For example, a hospital discharge summary in the physician's office may not be signed, while the same version of the hospital discharge summary in the hospital is signed and dated. Billing providers are encouraged to review their documentation for signatures before sending records to the contractor reviewer, or attach a signature log or attestation statement.


If at any time the contractor suspects evidence of fraud, which could include a pattern of missing/illegible signatures, this will result in a referral to the PSC/ZPIC.


Alternatives for Legible Signatures


If the signature is illegible, contractors will review evidence in a signature log or attestation statement to identify the author of the medical record entry. If the signature is missing from an order, contractors shall disregard the order during the claim review. If the signature is missing from any other medical documentation, a signature attestation from the author of the entry will be accepted.


As listed below, there are several scenarios that constitute compliance with this rule. Specifically:


  • Legible full signature;
  • Legible first initial and last name;
  • Illegible signature over a typed or printed name;
  • Illegible signature accompanied by letterhead, addressograph or other information on the page that indicates the author's identify;
  • Illegible signature with documentation that is accompanied by a signature log or an attestation statement;
  • Initials over a typed or printed name;
  • Initials not over a typed/printed name, but accompanied by a signature log or an attestation statement;
  • Unsigned handwritten note with other signed entries on the same page, writtenin the same handwriting.


Signature Log. As part of a patient's medical record, providers may submit a signature log that includes the author's typed or printed name associated with initials or an illegible signature. CMS recommends that the log include the provider's credentials, but failing to include them does not constitute a reason for denial.


Signature Attestation. The documentation may include the fact that a provider submitted an attestation statement (note that there is no required format for this statement). To be considered valid for Medicare medical-review purposes, the author must sign and date this statement, and it must contain sufficient information to identify the beneficiary. Contractors will not consider attestation statements from anyone (such as a partner in the same physician group) other than the author of the medical record entry (or attestation). Attestation statements also won't be considered when there is no associated medical record entry.


In the transmittal, CMS provided the following as an example of an acceptable attestation statement:


"I, [print full name of the physician/practitioner], hereby attest that the medical entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability."


Noncompliance with Requirements


The contractor may contact the billing provider and ask for a signature log or attestation statement within 20 calendar days. This time frame begins when the contractor makes a phone call or at the postmark time on a sent letter. Note that no such contact will be made when the claims should be denied for reasons unrelated to the signature requirement.


The following circumstances identify noncompliance with the signature requirement:


  • Illegible signature not over a typed/printed name and not on letterhead, with no signature log or attestation statement accompanying documentation;
  • Initials not over a typed/printed name and not accompanied by a signature log or attestation statement;
  • Unsigned, typed note with provider's typed name;
  • Unsigned, typed note without provider's typed/printed name;
  • Unsigned handwritten note (the only entry on the page); and
  • Statement such as "signature on file."