What is a Valid Anesthesiologist’s Signature on a Medical Record, and What Does it Mean?

What does it mean when an anesthesiologist signs a patient’s medical record?  What happens if the anesthesiologist’s signature is missing?

In general, a signature has three basic purposes:

Intent. The signature indicates confirmation that the signing party reviewed and approved the content or that s/he authored the document and approved the content.
Integrity. The signature protects the integrity of the document against a claim that the entry was invalid or that it had been altered.
Identity. The signature identifies the signing party.
In the healthcare context, for medical review purposes, Medicare requires that the treating or ordering practitioner authenticate the services in question, with very few exceptions.  The method used must be a handwritten or electronic signature.  (Program Integrity Manual Chapter 3 Section 3.3.2.4)

The point of the practitioner’s signature in patients’ medical records, operative reports, anesthesia records, orders and, test findings is to demonstrate that services reported to Medicare have been accurately and fully documented, reviewed and authenticated.  Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.

The exceptions to the authentication requirement are:

Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
There are some circumstances for which an order does not need to be signed.  For example, orders for some clinical diagnostic tests are not required to be signed and for which a progress note can adequately show the physician’s intent.
Signature requirements in specific, relevant regulations or Medicare policies or manuals take precedence over general principles.
Practitioners with physical disabilities preventing them from signing may use rubber stamps.
The Program Integrity Manual and the Medicare Learning Network fact sheet “Complying with Medicare Signature Requirements” provides ample detail on the types of signatures that are, and are not, acceptable.

Handwritten Signatures – Acceptable

Legible full signature
Legible first initial and last name
Illegible signature over a typed or printed name
Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signing provider.  Example:  An illegible signature appears on a prescription.  The letterhead of the prescription lists three physicians’ names.  One of the names is circled.
Illegible signature not over a typed/printed name and not on letterhead, but the submitted documentation is accompanied by: 1) a signature log, or 2) an attestation statement
Initials over a typed or printed name
Initials not over a typed/printed name but accompanied by: 1) a signature log, or 2) an attestation statement
Unsigned handwritten note where other entries on the same page in the same handwriting are signed
Electronic Signatures – Acceptable

The Program Integrity Manual validates the use of electronic signatures, but warns physicians and others that:

Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods.  For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws.  The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.  Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.
Examples of acceptable electronic signatures include the following, taken from Palmetto GBA’s “Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices:”

Chart 'Accepted by' with provider’s name
'Electronically signed by' with provider’s name
'Verified by' with provider’s name
'Reviewed by' with provider’s name
'Released by' with provider’s name
'Signed by' with provider’s name
'Signed before import by' with provider’s name
'Signed:  John Smith, M.D.' with provider’s name
Digitized signature: Handwritten and scanned into the computer
'This is an electronically verified report by John Smith, M.D.'
'Authenticated by John Smith, M.D'
'Authorized by: John Smith, M.D'
'Digital Signature: John Smith, M.D'
'Confirmed by' with provider’s name
'Closed by' with provider’s name
'Finalized by' with provider’s name
'Electronically approved by' with provider’s name
'Signature Derived from Controlled Access Password'
If the signature on the medical record or order is unacceptable, because, for example, it is on an unsigned typed note without the physician’s typed or printed name, or because the record merely indicates “signature on file,” the Medicare contractor will contact the provider or billing entity and give them 20 days to submit an attestation statement or signature log (unless the claim is to be denied independently, for reasons unrelated to signature requirements.)

A signature log can be created at any time.  It may be an individual log or a group log and is a typed listing of the provider(s) identifying their name with a corresponding handwritten signature.

An attestation is a declaration submitted to authenticate an illegible or missing signature on medical documentation.  To be valid for Medicare, it must include:  (a) the printed full name of the physician or other practitioner, (b) sufficient information to identify the beneficiary, (c) the date of service (d) the signature of the physician or practitioner and (e) the date on which signed.  WPS Health Insurance, the Medicare Administrative Contractor (MC) for a number of Midwestern states, provides the following example of an attestation:

The Medicare MACs provide further information on their individual websites; it may also be worthwhile to check whether your managed care payers have specific requirements.  Signatures are not the proverbial rocket science, but they are critical.  Any request from a MAC or other reviewer for a log or attestation should receive a speedy response so that payment is not delayed.