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					                                                                                               NHIC, Corp.
                                                                  MEDICARE ADMINISTRATIVE CONTRACTOR
                                                                                JURISDICTION 14 A/B MAC



When Responding to Comprehensive Error Rate Testing (CERT)
Medical Records Requests for Labs, Diagnostics and Therapeutic
Services – M. D. Order or Progress Notes with M.D. Signature -
Guidelines

All medical records must have a legible identifier, signature or initials, on the patient’s
permanent records before the claim is submitted to Medicare.

Listed below are some examples of medical records that require a legible signature:
• Dictated reports – provider should proofread the dictation
• Outpatient visits
• Lab or Diagnostic Orders/Requisitions and copy of the physician’s progress notes
    requesting the test to be performed
• Certification of Medical Necessity (CMN)
• Treatment Plans/Plan of Care
• Treatment logs/notes
• Initial evaluations or current re evaluations
• Inpatient visits – if necessary obtain the signed copy from the hospital
• Office visits – even if there is only one provider at the practice location

If the signature is illegible on the hardcopy record, include the signature log or attestation
with the documentation request. The signature log is a document prepared by the physician
or compliance officer showing the physician’s typed name and signature.

If late entry to your records is needed, for illegible signature, – you may use an attestation
statement such as below per CMS Internet-Only Manual (IOM) Publication 100-08 Chapter 3
Section 3.4.1.1B1b. Please do not have provider alter the records by signing the unsigned
medical record.

Example attestation statement - “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.”

If using an electronic medical record system, include a copy of the protocol describing the
requirement of the physician to enter the electronic system with a unique ID and password
to place his/her electronic signature on the document. The screen print of the electronic
record should also include indication of the MD signature such as “Electronically signed by”.



                                                   NHIC, Corp.
                                           75 Sgt. William Terry Drive
                                              Hingham, MA 02044
                                             www.medicarenhic.com
                                     TMP-EDO-0066 V1.0 Release date: 02/04/2011
The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either
electronic or paper, is uncontrolled and must be destroyed when it has served its purpose.
                                                                                               NHIC, Corp.
                                                                  MEDICARE ADMINISTRATIVE CONTRACTOR
                                                                                JURISDICTION 14 A/B MAC



For services that require a physician’s order such as inpatient hospital stay, labs, diagnostic
and therapeutic services - clearly identify the following:
• Physician’s intent to order; and
• Medical necessity of the services.

Documentation submitted will need one of the following items showing physician intent and
medical necessity:
• Order form, requisition form or treatment plan with physician typed name, signature and
   progress notes showing clinical conditions that necessitate services billed
• Screen print of electronic request by the physician is acceptable for all services except
   controlled substance drugs. With electronic system requests, also include progress notes
   showing clinical conditions requiring services and one of the following:
      o Copy of your protocol with requirement of physician logon ID and password to
           order the tests or procedures (Protocol can be sent once per provider.)
      o Evidence of physician entry into the request system with individual logon ID and
           password such as audit trail that proves the doctor entered the request for
           services electronically

If no M.D. typed name or signature is not clearly legible - include one of the following:
• Signature log – a document prepared by the physician or compliance officer showing
    typed or printed physician’s name and signature
• Signature attestation – per CMS IOM Publication 100-08 Chapter 3 Section 3.4.1.1B1b 1.
    example attestation statement - “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.”

• M.D. signature as late entry not accepted

For additional questions or clarification - NHIC J14 A/B MAC Provider Call Center
Part A providers - (877) 757-7783, RHHI providers - (866) 289-0423




Published: October 14, 2010
Revised: July 7, 2011




                                                   NHIC, Corp.
                                           75 Sgt. William Terry Drive
                                              Hingham, MA 02044
                                             www.medicarenhic.com
                                     TMP-EDO-0066 V1.0 Release date: 02/04/2011
The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either
electronic or paper, is uncontrolled and must be destroyed when it has served its purpose.

				
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