Legible Provider Signature on All Office Notes 

Since IPC Billing usually bills office services from the coded encounter forms submitted, we have no way to verify if the applicable office notes are appropriately signed by the provider. We wanted to remind our clients that the CERT review process is now strictly enforcing a long standing rule that requires a legible signature on all clinic notes, orders and other documentation (e.g. procedure notes) used to substantiate a claim billed to Medicare. Failure to have a written or electronic signature on these items may result in a payment denial regardless of the medical necessity. Physicians also must countersign notes, when applicable, of NP, PA, etc. who work under physician direction. Electronic signatures should clearly show that the item has been electronically signed and include a date and if possible a time.

We also advise that your office keep a signature sheet for each provider. This sheet should include the physician's written signature and his/her legible printed or typed name. If a physician written signature is not legible, this signature sheet should also be included with any submissions to the CERT carrier or the RAC carrier. Scrawled illegible initials will not suffice, but clear, legible initials accompanying a typed or printed name will usually be acceptable with the initials noted on the signature sheet.