CMS guidelines mandate the presence of signatures for medical review purposes. However, records pertaining to any procedures billed to Medicare are potentially subject to review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action. Show
Note: Be aware that electronic and digital signatures are not the same as "auto-authentication" or "auto-signature" systems, some of which do not mandate or permit the
provider to review an entry before signing. Indications that a document has been "Signed but not read" are not acceptable.
Acceptable Written Signatures
Unacceptable Signatures
Unacceptable Signature Examples
Example: Signing physician: ______________________
Example: Confirmed by: ______________________
Example: Dictated by: ______________________
If the signature requirements are not met, Palmetto GBA will contact the person or organization that submitted the claim(s) and ask him/her to submit an attestation statement or signature log. The attestation or signature log must be received in our office within 20 calendar days of the call or the date the written request is received by the post office. Example Attestation Statement: An attestation statement may be submitted to authenticate an illegible or missing signature on medical documentation. In order to be considered valid for Medicare medical review purposes, your attestation statement must include the following elements:
Example “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.” While the above statement is an acceptable attestation format, at this time Palmetto GBA is neither requiring nor instructing providers to use a certain form or format.
Unique Signature Situations
Electronic Medical Records: Recommendations The electronic system you select should include a process that verifies the individual signing his or her name has reviewed the contents of the entry and determined it contains what he or she intended. Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic signatures, by whatever method, by anyone other than the designated individual to whom it is assigned. It is to be unique to the individual, and not reassigned nor reused by someone else. Furthermore, measures should be in place to protect the links between electronic health information and signatures which prevent unapproved alteration through removal, copying or transfer. To avoid unnecessary payment denials, rejections, or overpayment situations, we strongly urge providers to check with their technical staff or software vendors to verify
their current record-keeping and signature processes are in compliance with CMS instructions. Software and hardware should meet or exceed industry standards to avoid compromising the integrity of documentation and signatures.
For more information please review the Signature Requirements: Acceptable Examples Job Aid (PDF). Which of the following is the correct order when filing patients records?Patient records are filed in strict chronological order according to patient number from lowest to highest. It is a common practice that medical record numbers contain six digits.
What are the steps to file patient records quizlet?Terms in this set (5). Inspect. MA and provider read thru patient report.. Index. to make a decision about the name, subject, or other identifier under which you file the material.. Code. mark the index identifier on the papers to be filed. ... . Sort. ... . Store.. What are the preferred steps for filing medical documentation?The preferred order for steps in filing medical documentation is: Inspect, index, code, sort, file.
What are the five steps involved in filing?The five basic steps for filing. Conditioning, releasing , Index and coding, Sorting, Storing and filing.
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