Outpatient Facility Coding Alert - 2019 Issue 1
Practice Management: Duck Signature-Error Denials With These Steps
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Article Overview
This practice management article reviews Medicare and CMS signature documentation requirements, including authentication, attestation, signature logs, electronic signatures, and recognized exceptions. It is aimed at coders, compliance staff, and providers who want to understand general signature-related documentation standards and avoid denials tied to missing or insufficient signatures.
Why This Topic Matters
Signature problems are a frequent source of claim denials and compliance findings, so understanding the broad documentation expectations can help healthcare organizations protect reimbursement and strengthen recordkeeping.
Article Sections
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Step 1: Know When the Signature Itself Needs Support
Explains when a signature may need supplemental documentation and introduces general supporting documentation concepts used to verify identity in the medical record.
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Step 2: Determine Who Must Sign
Covers who is expected to sign documentation and discusses how this applies in both paper and electronic record environments, including services performed incident to another provider.
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Step 3: Consider the Exceptions
Summarizes broad categories of exceptions and other authority that can affect signature requirements, including certain Medicare and CMS-related situations.
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Step 4: Find out Which E-Signatures Work
Provides general examples of electronic signature formats discussed in the article and the types of wording commonly recognized in electronic records.
What You Will Learn
- The general Medicare and CMS expectations for authenticating medical record entries
- When supplemental documentation may be used to support a signature
- How signature requirements relate to the author of the record
- Which broad categories of exceptions may apply to signature rules
- What kinds of electronic signature formats are discussed in the article
Who Should Read This
- Medical coders
- Compliance staff
- Billing and revenue cycle professionals
- Physicians and other providers
- Practice managers
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