Medicare Documentation Signature Timeliness

Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature.  Unless the documentation for a service is completed; including signature; a provider cannot submit the service to Medicare.  Medicare states if the service was not documented, then it was not done.

Providers are expected to complete the documentation of services "during or as soon as practicable after it is provided in order to maintain an accurate medical record." This statement is from the Centers for Medicare & Medicare Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, (PDF) Section 30.6.1. CMS does not provide any specific period, but a reasonable expectation would be no more than a couple of days away from the service itself.

Additional Resources

• The CMS IOM Publication 100-08, Chapter 3 (PDF), section 3.3.2.4 discusses the requirements for practitioner signature: "Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process"
• The CMS IOM Publication 100-08, Chapter 3 (PDF), section 3.3.2.5, discusses late entries. A provider should never add a signature to a medical record after the times discussed above. If a physician does not affix a signature at the time of the service (also allowing limited delay due to transcription), then the provider may complete an attestation statement. 
• Change Request (CR) 6698 (PDF)
• The CMS Fact Sheet entitled, "Complying with Medical Record Documentation Requirements" (PDF) 
• The article by the American Academy of Professional Coders (AAPC) entitled, "Medical Record Entry Timeliness: What Is Reasonable?"
• Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices 
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  • JJ Part B
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  • JM Part B
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