Podiatry Coding & Billing Alert

Medicare requires that all services provided or ordered be authenticated by the author of the medical record, O’Leary said. The appropriate method used for authenticating is either a handwritten or electronic signature.

Take a look at some examples of medical records requiring a signature, according to O’Leary:

• Dictated reports
• Outpatient visits
• Lab/diagnostic orders/requisitions
• Certificates of medical necessity
• Treatment plans/plan of care
• Treatment log notes
• Initial evaluations or current reevaluations
• Inpatient visits
• Office visits

Rule 2: Follow Electronic Signature Guidelines

Medicare has specific guidelines for electronic signatures. They are as follows:

• The systems and software your office uses must be protected against modification.
• Your administrative safeguards should follow standards and laws.
• Teach your office that whoever’s name in on the alternate signature method and the provider are taking responsi­bility that the attested info in the medical record is true.
• Include a copy of your office’s electronic signature protocol procedure.

Rule 3: Handle Illegible Signatures Like This

In some cases, your provider’s signature may be illegible. If this happens, you can submit a signature log or an attestation statement, according to Langevin. Signature logs and attestation statements support the identity of the illegible signature.

You can automatically send the signature log/attestation statement along with your medical documentation to your MAC, Langevin added. Doing this will help avoid delays in the review process.

Rule 4: Understand Importance of Signature Log

A signature log is one method to support the identity of an illegible physician signature.

A signature log is a typed listing of the provider or providers identifying their name with a corresponding handwritten signature, O’Leary said. The providers’ credentials are required, and the signature log must be part of the patient’s medical record.

Don’t miss: You may include the signature log on the same page where the initial or illegible signature is located or in a separate document, according to O’Leary. Just make sure that the signature log is a part of the patient’s medical record.

“A signature log can be created at any time,” Langevin added. “MACs will accept all submitted signature logs, regardless of the date they were created.”

Rule 5: Attestation Statements Can Support Illegible Signatures

You can also submit an attestation statement if your provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, according to O’Leary. The statement must also include the appropriate patient information.

Caution: You can’t include a blank attestation statement with no patient identification information, O’Leary said. The statement must be personalized for each patient and signed by the physician.

Rule 6: Remember Stamped Signature Exception

Medicare will allow stamped signatures, but only under a very special circumstance.

“Medicare will permit a rubber stamp for signatures in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability,” Langevin said.

The author of the medical record who has the physical disability must prove their inability to sign the record due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the documentation.