Legible Medical Records

Submitted by Matthew.Gregor… on Mon, 11/04/2019 - 07:41
Legible Medical Records

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature.

If the signature is illegible or missing from the medical documentation (other than an order), the review contractor shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.

If the signature is missing from an order, the review contractor shall disregard the order during the review of the claim (i.e., the reviewer will proceed as if the order was not received). Signature attestations are not allowable for orders.

For more information, refer to MLN Matters® Special Edition Article SE1237 (PDF) .