By Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq.


One way providers can avoid Medicare audit denials is to be aware of, and in compliance with, CMS’s recently updated signature guidelines.


Contractors engaged in medical review activities are instructed to apply the new signature requirements for reviews occurring on or after April 16, 2010.


The new guidelines clarify the signature requirements set forth in the Medicare Program Integrity Manual. Previously, the manual language required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. The new requirements expand on the existing guidelines, requiring that services provided/ordered be authenticated by the author. Handwritten or electronic signatures are listed as acceptable methods of authenticating documentation, whereas stamp signatures expressly are excluded.


Signature Logs


With respect to handwritten signatures, the revised manual sections include a table that provides examples of when requirements have and have not been met. In cases in which the requirements have not been met, such as if a signature is found to be illegible, the contractor is instructed to consider using a signature log or signature attestation statement to determine the identity of the author.


A signature log lists the typed or printed name of a provider associated with initials or an illegible signature. It also may be helpful for providers to list their credentials on the signature log as well. The guidelines require contractors to consider signature logs regardless of the date they were created.


Signature Attestation


Signature attestation statements are another way for providers to authenticate medical documentation. The attestation must be signed and dated by the author of the medical record entry at issue and it must identify the beneficiary who was provided or ordered services. It is important for providers to recognize that an attestation cannot take the place of a medical record entry, that is, an attestation statement may not be considered when there is no associated medical record to authenticate.


A signature attestation statement from the author of a medical record also will be considered if the provider’s signature is missing from the documentation at issue. This requirement applies to all medical documentation missing a signature other than an order. In cases in which a provider’s signature is missing from an order, contractors are instructed to disregard the order in the review of the claim. The claim is reviewed as if the order was not included in the medical records submitted. As providers might expect, the absence of an order almost certainly will increase the likelihood of claim denials for most services covered by Medicare.


When a signature is illegible or missing, the guidelines require the contractor to contact the billing provider or organization to request that an attestation statement or signature log be submitted. Providers are given 20 calendar days to submit a requested log or attestation starting from the date the contractor makes contact with the provider (or the postmark date on a written request letter). If the provider submits the requested information, the contractor is afforded an additional 15 days to review the claim, thereby extending the timeframe for review from 60 to 75 days.


The signature authentication process is intended to provide a signature assessment in situations in which the Medicare criteria is met except for a key piece of documentation missing a signature or containing an illegible signature. It is in this case that the contractor is required to initiate the signature authentication process.


Failure to Comply


Contractors are not required to proceed with signature authentication if the claim can be denied for reasons unrelated to the signature requirements. In the context of audit activities, failure to comply with the signature guidelines essentially creates a denial rationale for what otherwise may be a covered Medicare claim. Providers can prevent claim denials by understanding and implementing practices that satisfy the signature guidelines.


One practical measure providers may want to consider is implementing signature logs as part of their compliance program before being subject to an audit. This will be particularly important in instances in which a person who created a medical record at issue in an audit no longer is employed by the provider or organization. If the signature on the record is illegible, an existing signature log listing the employee’s initials or illegible signature could be submitted and considered by the contractor.




If a signature log was not in place during that individual’s employment, it may be difficult or impossible to locate the person for the purposes of creating a log to submit. Furthermore, as previously discussed, providers only are given a 20-day timeframe in which to comply with a request for a signature log or attestation. Also, if the signature log is readily available, it can be submitted to the reviewers at the beginning of an audit.


In the context of prepayment medical reviews and additional documentation request (ADR) letters, contractors may advise providers that in order to comply with the new signature requirements, they need to contact the hospital or other facility where services were provided in order to obtain a signed copy of the medical records. For instance, the copy of a hospital discharge summary kept in a physician’s office file may be unsigned while the copy in the hospital chart is signed and dated. Providers who are billing for services provided in an outside hospital or other facility may want to have a system for obtaining copies of signed documentation in the other entity’s possession.


It may be difficult to obtain copies of the signed documentation needed quickly when trying to respond to multiple ADR requests or a post-payment review in a timely manner.


About the Authors


Amy K. Fehn is a partner at Wachler & Associates, P.C.  Ms. Fehn is a former registered nurse who has been counseling healthcare providers for the past eleven years on regulatory and compliance matters and frequently defends providers in RAC and other Medicare audits.


Jennifer Colagiovanni is an attorney at Wachler & Associates, P.C. Ms. Colagiovanni graduated with Distinction from the University of Michigan and Cum Laude from Wayne State University Law School.  Upon graduation, Ms. Colagiovanni was nominated to the Order of the Coif. Ms. Colagiovanni devotes a substantial portion of her practice to defending Medicare and other third party payer audits on behalf of providers and suppliers.  She is a member of the State Bar of Michigan Health Care Law Section.


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