Is It Valid? A Guide to Signatures and Addendums

It’s not uncommon for an appeal to be denied or an audit to occur based on a technicality related to the signature and addendums of medical records. As a result, the subtle nuances of both can leave suppliers and providers asking the age-old question: Is it valid?

T he signature is needed on everything from the order to the proof of delivery, and one misstep in the signature can render an entire document invalid. Not as common as it once was, the “wet” or handwritten signature is still a valid method for authenticating a record. Ideally, it will be legible, although if it isn’t, a signature log is an acceptable supporting document to validate an illegible signature. The signature should also include credentials, but this can be verified in other ways and would only be called into question if it is suspected that the author does not have the required credentials to conduct the service for which they are documenting.

More common in the age of electronic medical records (EMRs) are electronic signatures. To be considered valid, an electronic signature must contain the name and date and identify itself as electronically captured (e.g., authenticated by, electronically signed by, digitally captured by, etc.). The electronic signature should also reflect the credentials of the author, however, just like the wet signature, it too can be verified in other ways if not captured in the signature. Familiarize yourself with the types of electronic signatures captured by the EMR software your referral sources use so you can quickly identify whether the document is properly authenticated.

The general rule of thumb is that a signature is not valid unless it is dated, unless the document being signed does not require a signatures date (e.g., a Standard Written Order).

An important reminder about signatures is that the above information does not just apply to treating practitioners and their signatures, it also applies to the clinicians in your practice. Orthotists, prosthetists, and fitters should all be signing and dating every patient visit documented for those records to be considered valid.

If an addendum or amendment is needed on the document (whether practitioner or clinical documentation), it’s critical that the added or changed information be appropriately captured to be considered valid in a claim review. When adding information to the record, it must be clearly identifiable what information is original to the record and what information has been added. If information is being changed instead of added, a single-line strike-through should be made through the original/incorrect information, followed by the new/correct information. The document must also reflect when the information was added/changed and by whom. Last, but certainly not least, the additions/changes must be initialed and dated by the author.

Timeliness is an often-hidden element that can sneak up and render your claim not payable, so paying close attention to dates and date spans for all documents and signatures is critical. Although not clearly defined by Medicare, signatures and addendums should be timely. Initial signatures on things like medical records should take place on the date of the evaluation for which the documentation is created, although signing it within a few days is acceptable. Also not defined is the timeframe within which an addendum or amendment may take place. Despite the lack of definition, this still causes claim denials if the original medical record does not satisfy policy requirements and the addendum was created too long after the original office visit date. For this reason, it is strongly recommended that medical records be requested/obtained prior to delivery of the item for review. This provides the supplier/provider with time to review for compliance and request a timely addendum/amendment. Waiting until a formal claim review (i.e., an appeal or audit) to review medical records can result in a necessary addendum to not be timely, which may render it invalid and likely cause the claim to be denied.

Brush up on Medicare Signature Requirements in the Program Integrity Manual, Chapter 3, section 3.3.2.4 and Amendments, Corrections and Delayed Entries in Medical Records, Chapter 3, section 3.3.2.5 (cms.gov/regulations- and-guidance/guidance/manuals/ downloads/pim83c03.pdf).

Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are partners at O&P Insight. O&P Insight is a consulting and billing company specializing in the O&P industry. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can reach Sisson or Bertram at leseligh@oandpinsight.com or curt@oandpinsight.com. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.

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