Physicians have always been known for having the absolute worst handwriting. Although often the subject of jokes, the illegible scribble of a physician can have dire consequences on the life of a patient if orders or prescription dosages are misread, and on an agency’s revenue if claims are denied as a result of an illegible signature. Medicare has adopted precise guidelines on what are acceptable and unacceptable signatures on medical records and documents. Failure to follow these guidelines can lead to claims being denied and payment recoupment.

Acceptable Signatures on Medical Records and Documents

According to CMS, for a signature to be valid, the following criteria must be met:

• Services that are provided or ordered must be authenticated by the ordering practitioner
• Signatures are handwritten, electronic, or stamped (stamped signatures are only permitted in the case of an author with a physical disability who can prove proof to a CMS contractor of inability to sign due to a disability)
• Signatures are legible

The defining word here is “legible”. The dictionary defines legible as "that can be read." If you can read someone's handwriting, it is legible. The person might not have perfect penmanship, but if you can decipher the letters, the writing is legible.

CMS states that if the physician signature is not legible then the agency must submit either a signature log or an attestation statement to support the identity of the illegible signature.

What is a signature log?

A signature log is a typed listing of provider names followed by a handwritten signature. The purpose of a signature log is to identify the provider of a service when the signature is either illegible, partial or uses initials. A signature log can be created at any time and Medicare will accept all submitted signature logs regardless of the date on which they were created.

What is a signature attestation?

A signature attestation is a statement that must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. The attestation statement must be associated with a medical record entry. Attestation statements from someone other than the author of the medical record entry in question are not acceptable.

Acceptable signature examples:

1. Legible full signature
2. Legible first initial and last name
3. Illegible signature over a typed or printed name
4. Illegible signature where the letterhead, addressograph or other information on the pages indicates the identity of the signer
5. Illegible signature not over a typed/printed name and not on letterhead, but the submitted documentation is accompanied by a signature log or attestation statement
6. Initials over a typed or printed name
7. Initials not over a typed/printed name but accompanied by a signature log or attestation statement
8. Unsigned handwritten note where other entries on the same page in the same handwriting are signed

Unacceptable signature examples:

1. Illegible signature not over a typed/printed name not on letterhead and the documentation is unaccompanied by a signature log or attestation statement
2. Initials not over a typed/printed name unaccompanied by a signature log, or attestation statement
3. Unsigned typed note with provider’s typed name
4. Unsigned typed note without providers typed/printed name
5. Unsigned handwritten note, the only entry on the page
6. “Signature on File”

It is imperative that providers maintain compliance and implement measures to ensure that they are following the Medicare signature requirements to avoid unnecessary refunds. Validating signatures should be a standard part of the chart audit review. Obtaining an attestation statement or maintaining a signature log ensures that a provider will have sufficient documentation to support the services provided and should become standard practice.

Sources:  Medicare Program Integrity Manual (Pub. 100-08), Chapter 3

Medicare Learning Network (MLN) Matters “Complying with Medicare Signature Requirements”