Did you know that there are Medicare electronic signature requirements? CMS has specific guidance on the use of electronic signatures which is applicable to not only therapy notes in your own EMR, but electronic signatures for certification of the plan of care. The following guidelines for electronic signature are found in the Medicare Program Integrity Manual, Chapter 3, Section 184.108.40.206 E-F. In stating that there is a need to recognize that there is potential for misuse or abuse with the electronic signature as an alternate signature methods CMS guidance states:
…..providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.
Have you received physician orders and certifications that are electronic? Do you have an EMR in which you electronically sign all the required Medicare documentation elements? Do you have the proper administrative safeguards in place to protect the individual signators in your EMR system? Have you asked you therapy EMR vendor to provide you with verification that the software is protected against modification and safeguards your signatures?
Medicare Electronic Signature Requirements – Who Signs?
Some additional food for thought: Who has access to your EMR log-on information? If a PTA or COTA provide therapy, do they also sign the note, if the therapist provided treatment during the same session?