No Signature Means No Order for Medicare Auditors

June 21st, 2010

One of the areas Medicare auditors are instructed to review during audits is the signatures of medical records.  In fact, if a required physician's signature is missing from an order that requires a signature, auditors have been instructed to completely ignore the medical record or order. 

CMS has recently updated MLN Matters Number MM698 to define what is a legible signature.  On pages six and seven of the bulletin, a chart that summarizes signature and legibility requirements is included.  See:

https://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf

There are some surprises in the publication.  For example, signature by attestation is allowed.  A suggested format for the attestation is provided within the article.

Initials are only acceptable is over a typed name or accompanied by a signature log or attestation statement.

A dictated and typed medical report even if initialed is insufficient unless the physician initials over a typed name (or there is an accompanying signature log or attestation statement.)

Surprisingly, some items do not require a signture.  For example, orders for clinical diagnostic tests are not required to be signed. But if the order for the clinical diagnostic test is unsigned, there must be some form of documentation by the treating physician (e.g., a progress note) that he intended for the clinical diagnostic test to be performed. This documentation must be signed.

Not knowing and applying signature requirements could be a costly mistake.  The MLN Matters cited above should be mandatory reading.

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