When is an Anesthesiologist’s Signature Good Enough for Medicare?


June 27, 2011

Some things should not be this complicated.

Physicians’ and other providers’ signatures have come under renewed scrutiny, however, because the national Medicare Fee For Service (FFS) Error Rate for the most recent reporting rate was 7.8 percent. That translates to more than $24 billion paid in error. According to the Certified Error Testing Rate (CERT) report for the first quarter of 2011,

The majority of the errors for insufficient documentation were related to the fact that the medical record did not contain a valid physician’s signature in the documentation or that the radiology report/diagnostic test performed did not contain a valid physician order or an identification of the provider who rendered the service. Other insufficient documentation errors consisted of documentation that did not adequately describe the service defined by the reported Current Procedural Terminology (CPT) code, Healthcare Common Procedure Coding System (HCPCS) code, or HCPCS modifier billed; documentation that did not support the Internal Classification of Disease (ICD-9) Code billed; lack of physician signature on the medical record for the physician certification/plan of care; and insufficient documentation to support the service billed. (Emphasis in original)

The Centers for Medicare and Medicaid Services (CMS) developed the CERT program to produce a national Medicare FFS error rate, as required by the Improper Payments Information Act of 2002. Under the CERT program, contractors randomly select a nationwide sample of about 50,000 Medicare FFS claims and review those claims and medical records obtained from the providers/suppliers who submitted the claims, for compliance with Medicare coverage, coding, and billing rules.

The CERT methodology involves:

  • Requesting medical records from the providers that submitted the claims in the sample.
  • Where medical records were submitted by the provider, reviewing the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigning errors to the claims.
  • Where medical records were not submitted by the provider, classifying the case as a no documentation claim and counting it as an error.
  • Sending providers overpayment letters/notices or making adjustments for claims that were overpaid or underpaid.

Since we last explored the topic of acceptable signatures in our Alert of September, 20, 2010, anesthesia practices have continued to encounter difficulties in this area. Notices such as the following from contractor CGS Administrators, LLC help to stoke the confusion:

This notice is intended to help you understand that an error will be assessed when a medical record does not include a LEGIBLE IDENTIFIER (signature) of the author (a typed or printed name must accompany initials).

This error will cause an overpayment and a recoupment of funds.

The OIG and CERT have made it clear that the signature requirement must be enforced and signatures (a typed or printed name must accompany initials), hand written or electronic, must be present on ALL documentation and MUST BE LEGIBLE. (Emphasis in original.)

Logically enough, one participant on the MGMA-Anesthesia Administration Assembly (AAA) listserv questioned whether that meant that an anesthesiologist or CRNA name must “be printed or typed on every anesthesia record in addition to the signature or initials? I doubt that many MD/CRNA signatures and initials are ‘legible.’"

The answer is no. The Medicare requirements are quite logical in this regard. If there isn’t a legible signature on each anesthesia record, there are signature logs and attestations that will cure the deficit (see below). We hope to provide a sufficiently logical explanation here to put most questions to rest – at least until the rules change.

I. Signatures That Meet the Requirement

First, “A handwritten signature is a mark or sign by an individual, on a document, to signify knowledge, approval, acceptance or obligation.” MLN Matters Number MM 6698, revised on June 16, 2010. It is necessary because services provided or ordered must be authenticated by the provider. The basic rule is that the method of authentication shall be a legible hand written or an electronic signature – that may be on a document other than the anesthesia record such as a signature log or an attestation (see below). Stamped signatures, though, are not acceptable.


  • Legible full signature
  • Legible first initial and last name
  • Initials over a typed or printed name,
  • Illegible signature over a typed or printed name
    • Example:

      Anne Smith, MD
  • Illegible signature where letterhead or other information on page identifies the signatory
    • Example: Pre-printed prescription pad with prescribing MD’s name circled over illegible signature


Exceptions to requirement of handwritten or electronic signature:

  • Certification of terminal illness for hospice: fax acceptable
  • Clinical diagnostic tests: if order is unsigned,
    • there must be documentation by treating physician showing intent to perform, and
    • authenticated documentation must have handwritten or electronic signature
  • If regulation, National or Local Coverage Determination, or CMS manuals have specific requirements, they take precedence

Not acceptable:

  • Unsigned, typed note with physician’s name typed only
  • “Signature on file”
  • Unsigned typed note without physician’s typed or printed name
  • Unsigned handwritten note and no other entry on the page
  • Initials not over a typed or printed name, and not accompanied by a signature log or an attestation statement.

II. Signing Electronic Health Records (EHRs)

The March, 2011 MedLearn Matters MLN Fact Sheet: Comprehensive Error Rate Testing (CERT) Signature Requirements provides the following guidelines for using an electronic signature:

  1. Systems and software products must include protections against modification, and you should apply administrative safeguards that correspond to standards and laws;
  2. The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information being attested to;
  3. Physicians are encouraged to check with their attorneys and malpractice insurers in regard to the use of alternative signature methods; and
  4. Part B providers must use a qualified electronic prescribing (e-prescribing) system.

III. If There Is No Acceptable Signature on the Medical Record

CMS has provided us with two safety valves:

1. The attestation statement

  1. Used when the signature is missing from the medical record(s) requested by a Medicare contractor for random review, or when the signature is illegible on such record(s).
  2. This is a declaration that must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.
  3. Reviewers will disregard an attestation statement where there is no associated medical record entry.
  4. Reviewers will not consider an attestation statement from someone other than the author of the medical entry.
  5. The date that the attestation was signed is unimportant, unless regulations indicated that a signature must be in place prior to a given date or event.
  6. Sample attestation language:

I (print full name of 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. MD, DO, CRNA) 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.

2. The signature log

  1. A typed listing of the provider(s) identifying their name and preferably their degree with a corresponding handwritten signature. (See MLN Fact Sheet: Comprehensive Error Rate Testing (CERT) Signature Requirements, March 2011.)
  2. Used when the physician’s signature is illegible or missing.
  3. This may be an individual log or a group log.
  4. It may be on a page within the documentation or it may be a separate document.
  5. Staff can create a signature log on behalf of a physician or CRNA at any time. Medicare contractors will accept all submitted signature logs regardless of the date on which they were created.

The signature log is the easiest solution, prophylactically and therapeutically. Ideally every anesthesia record will have a legible physician/CRNA signature, but that is not realistic for every practice. It may seem like another hassle to keep a sheet with the typed names of all the providers and their typical signatures. The purpose and benefit of such a log, however, is to prevent the practice from worrying about whether every record had a valid legible signature. Receiving a letter on Medicare letterhead with this introduction can be unnerving:

You are receiving this letter because the CERT program has randomly selected one or more of your claims for review. In accordance with 1833 of the Social Security Act, you must provide medical record documentation to support claims for Medicare services upon request. It is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary. Please provide the requested documentation as soon as possible. A response is required from you even if records for the sampled beneficiary for the dates of service listed cannot be provided.

If the CERT contractor sends you a letter requesting medical records documentation like the one quoted above, you can keep your blood pressure under control by being prepared with an up-to-date signature log for your group. Automatically attaching the up-to-date signature log to the submission to the CERT contractor is one way to minimize the incidence of follow-up requests.

A signature log can help you avoid the situation below, also described in the sample letter requesting medical records:

If the signature requirements are not met, CERT will conduct the review without considering the documentation with the missing or illegible signature. This could lead CERT to determine that the medical necessity for the service billed has not been substantiated.

In sum, it has taken CMS and the MACs reams of paper, and it has taken us about 1600 words to tell you that a CERT or other contractor should be able to tell whether you are indeed the author of the medical record under review. We hope that the signature issue will cause no further problems for any of our readers.


Tony Mira
President and CEO