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Physician Signature requirements

  1. #1
    Question Physician Signature requirements
    Medical Coding Books
    Does anyone have the CMS website for the requirements of Physician signatures on Office Note documentation? What must be included, how soon must physician sign off, especially for EMRs? Thanks!

  2. #2
    CMS Released August 5, 2009

    The CERT review process is now strictly enforcing a long standing rule that requires a legible signature on all clinic notes, orders and other documentation (e.g. procedure notes) used to substantiate a claim billed to Medicare. Section 1833(e) of the Social Security Act states that contractors must be able to identify the provider who performed the service in order to pay. CMS defines a legible signature or electronic signature as the appropriate ways of identification.

    Failure to have a written or electronic signature on these items will result in a denial regardless of the medical necessity.

    All Medicare providers billing Medicare for service shall ensure that their signature is attached to these documents. Each provider should immediately put into place a protocol to assure these items are signed within a reasonable time frame, usually 48-72 hours after the encounter but certainly before the claim is submitted.

    If a physician written signature is not legible, and many are not, please include a signature sheet with any submissions to the CERT carrier or the RAC carrier. This sheet should include the physician's written signature and his/her legible printed or typed name. If others have made entries on the items submitted it is recommended that they be included on this signature sheet. Scrawled illegible initials will not suffice, but clear, legible initials accompanying a typed or printed name will usually be acceptable with the initials noted on the signature sheet.

    Electronic signatures should clearly show that the item has been electronically signed and include a date and if possible a time.

    Providers should act quickly to adhere to this Medicare Program requirement to prevent unnecessary denials or delays in payment for appropriate services.

  3. #3
    Do you have a reference for this? I am assuming it's somewhere on the CMS website.
    Amy Crego, CPC, CPC-P, CPMA, CRC
    Vice President, Columbus, OH AAPC

    One can never consent to creep when one feels an impulse to soar. ~ Helen Keller

  4. #4
    Thanks for the link Rebecca. Unfortunately, Cigna isn't our carrier. I need a CMS reference.
    Amy Crego, CPC, CPC-P, CPMA, CRC
    Vice President, Columbus, OH AAPC

    One can never consent to creep when one feels an impulse to soar. ~ Helen Keller

  5. #5
    I did find this issued by CERT/CMS. did not save web site, but if you provide email i can scan you a copy.

  6. Default electronic signature
    does it meet the CMS requirements if the office note has the provider name with credentials listed at the top of the document, and the electronic signature only lists the provider name and date. - not including the credential?

    i.e. Signed by John Doctor on 02/02/08 at 10:00 AM

  7. Thumbs up e-mail address
    Quote Originally Posted by chrisrjjj View Post
    I did find this issued by CERT/CMS. did not save web site, but if you provide email i can scan you a copy.
    Please scan and send to me thanks!!

  8. #8
    Marion, OH
    If you are in Columbus, OH you can try this link:

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