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Signature requirements

  1. Default Signature requirements
    Medical Coding Books
    Has anyone ever had a Medicare denial because a progress note did not have a original physician signature?

  2. #2
    what do you mean by original ?

  3. Default
    Our transcriptionists type the physician name but the physician is not actually signing the document. I've been told that we should have the physician sign every document but I never had any denials for this reason.

  4. #4
    North Carolina
    Medicare will accept hand written, electronic signatures or facsimiles of original written or electronic signatures.

    Simply typing the physicians name doesn't meet the requirements. Unless Medicare reviews every record transcribed, you wouldn't have on-going denials. I am assuming they requested a medical record and denied it for this reason?

  5. Default signature question for medicare
    understanding written signatures are acceptable. What is the policy for the legability? I review progress notes that have the physician name at top but then the signature is illegible or maybe just a line. And if I'm able to somewhat read the name I cannot determine the credential in the squiggle.

    Secondly, what if the physician name and credential is not listed legibly on the note and just have the provider's signature - again all or part of the name is legible but can't read the credential.

    Where can I go on-line to view such a policy?

    Thank you

  6. #6
    North Carolina
    My "soon to be" new contractor, has a detailed policy....

    Signature's Purpose

    Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner's first and last name. For clarification purposes, we recommend you include your applicable credentials, e.g., P.A., D.O., or M.D.

  7. Default
    Thank you for your reply.

    So I am correct to say, even if a type name/credential is somewhere on the document, the "signature" must have a legible first/last name with credentials
    to be accepted by Medicare.

  8. #8
    Milwaukee WI
    Default Signature sheet
    We keep a master signature sheet where each provider's name, provider #, credential is printed and then s/he signs "as you would sign a note." We assign an internal provider number (just 5 digits), and we ask that providers (MD, DO, PA, NP, etc) both sign and add their number. Even those with terrible writing can manage to legibly include their number.

    This allows our chart abstractors to "decipher" the signatures accurately, and also gives us additional "proof" in an audit that this is truly Dr X's signature. (Of course, we are a pediatric practice so have virtually no Medicare patients.)

    Hope that helps,

    F Tessa Bartels, CPC, CEMC

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