Health Information Compliance Alert

Published on Sun Mar 13, 2011 PDF

Answers to 2 common questions help ensure you're on track.

Question 1: Some of our physicians use handwritten signatures on their charts and others prefer electronic signatures. Is either kind acceptable?

Answer 1: According to CMS documents, "Medicare requires a legible identifier for services provided/ordered." That "identifier" -- or signature -- can be electronic or handwritten, as long as the provider meets certain criteria. Legible first and last names, a legible first initial with last name, or even an illegible signature over a printed or typed name are acceptable. You're also covered if the provider's signature is illegible but is on a page with other information identifying the signer (letterhead, addressograph, etc.).

"Also be sure to include the provider's credentials," says Cindy Hinton, CPC, CCP, CHCC, founder of Advanced Coding Solutions in Franklin, Tenn. "The credentials themselves can be with the signature or they can be identified elsewhere on the note."

Example: Pre-printed forms might include the physician's name and credentials at the top, side, or end. All qualify as acceptable documentation as long as the coder or auditor can identify the provider's credentials.

You can also use a signature log to back up your physician's documentation. The log should contain each provider's printed or typed name and credentials, along with their signatures and initials. You can reference the signature log in order to verify a note that contains an otherwise unidentifiable signature. "This is an important resource when providers are signing notes that do not include their typed or pre-printed name," Hinton says.

Tip: Update signature logs at least once a year. Create separate logs by provider (physicians, CRNAs, AAs, residents, etc.) to help simplify tracking.

Watch out: Stamped signatures don't meet the CMS requirements. Because a signature stamp can be used by anyone who has access to the stamp, in essence it doesn't authenticate that the billing provider was the author of the supporting documentation. You can, however, use a typed or printed block print name below the provider's signature to clearly identify an illegible signature.

Question 2: Our office is in the process of switching completely to electronic medical records. Does that cover signature requirements for us?

Answer 2: Some coders or providers believe that electronic medical records (EMRs) do all the documentation work, but that's not necessarily the case. "Even electronic signatures must meet certain requirements," Hinton says. "Not all verbiage is created equal."

Considerations: As your providers incorporate EMR in their everyday care, double check the electronic signature's wording. Does it say, "Electronically signed by" or "Authenticated by"? Does it include the date? "There are numerous ways of phrasing and formatting the electronic signature," Hinton says. "Verify that the format you're implementing is approved by CMS."

Warning: "Electronic signatures carry the potential for misuse or abuse," says Judith Blaszczyk, RN, CPC, ACS-PM, of Auditing for Compliance and Education in Leawood, Kan. "System and software products should be protected against unauthorized modifications." Electronic capabilities should also comply with recognized standards and laws; check with your healthcare attorney and/or malpractice insurer to confirm compliance.