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Medical Coding News Archives

CMS Releases Stricter Authentication Guidelines for Medical Reviewers

April 6, 2010:

On March 16, the Centers for Medicare and Medicaid Services released new instructions for medical reviewers to follow regarding medical record authentication.

According to these new guidelines, the physician should authenticate all medical record documentation--including the operative reports--either by signing or at least initialing the report. A legible signature may be either handwritten or electronic. Stamp signatures are not acceptable. There are several exceptions to this requirement.

Exception 1: Facsimile of original written or electronic signatures is acceptable for certifying terminal illness for hospice.

Exception 2: There are some circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub. 100-02, chapter 15, section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g. a progress note) that he/she intended that the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.

Exception 3: Other regulations and CMS instructions regarding signatures (such as timeliness standards for particular benefits) take precedence.

Handwritten Authentication
According to CMS definitions, a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.

In the event that the signature is illegible, the review may consider evidence in a signature log (a list of the typed or printed name of the author associated with initials or illegible signatures) or attestation statement to determine the identity of the author of a medical record entry.

If the signature is missing from an order, however, medical reviewers shall disregard the order during the claim review. In the event that the signature is missing from any other medical documentation, the review must accept a signature attestation from the author of the medical record.

Physicians sometimes document using an attestation statement that documentation contained in the medical record was made by them. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and a specific document. CMS provides the following example of an acceptable attestation statement:

"I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above-listed Medicare beneficiary. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability."

Electronic Signatures
CMS urges providers using electronic systems to “recognize that there is a potential for misuse or abuse with alternate signature methods” and to ensure that electronic signatures are protected against modification, etc., and should apply administrative procedures that are adequate and correspond to recognized standards and laws. The agency encourages providers to check with their attorneys and malpractice insurers regarding the use of alternative signature methods.


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