Posted and filed under Compliance, Medical Record Auditing.

To a physician, providing authentication may appear as yet another inconvenience or hindrance to productivity in the midst of the already chaotic audit process – but it’s the difference between being reimbursed and having your claims denied. For the purpose of a medical record audit, Medicare requires that any services provided be authenticated within the medical record. Authentication is achieved through applying the physician’s signature to the medical records, handwritten or digitally. If the record author is disabled in a manner that prevents them from signing by hand or electronically, a stamped signature may be accepted.

Physician signatures must also be legible, consistent, and easily identified within the documentation in order to be considered valid.

These signatures must be present on the medical documentation prior to submission, as CMS does not accept late orders or signatures. Failure to comply will result in improper payments and/or rejections. One CERT study revealed that nearly 85% of improper payments were caused by insufficient documentation, including failure to provide signatures on procedure notes, and failure to submit a (legible) signature log or attestation form.

If the ordering physician fulfills the troubling stereotype of having illegible handwriting, the signature log and attestation statement will come in handy. Medicare will take these into consideration during the record review.

CMS defines a signature log as:

“…a typed listing of the provider(s) identifying their name with a corresponding handwritten signature. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation.”

If your practice does not currently utilize a signature log, it’s never too late to start. There are several templates available on line.

See Above: a Simple Signature Log template that can be customized to suit your needs.

Attestation statements serve a similar function in getting your claims accepted by allowing providers to attest that the signatures provided are in fact their own. CMS provides guidance on attestation statements, mentioning that all statements must be signed and dated by the record’s author, and contain sufficient information to successfully identify the beneficiary.

Again, if you are not already taking these steps to secure your position as a compliant provider – it’s not too late to start. A little extra work in the beginning will prevent the loss of time, money, and reputation in the future.