Signature compliance isn’t just about meeting a technical requirement. For Skilled Nursing Facilities (SNFs), it plays a direct role in ensuring Medicare reimbursement, defending claims during audits, and supporting timely, appropriate patient care. Facilities need to pay close attention to the Centers for Medicare & Medicaid Services (CMS) signature requirements.
What CMS Requires: Timely, Accurate, and Verifiable Signatures
CMS has long required that signatures on medical records be complete, legible, and timely. In most cases, that means within 24 to 48 hours, depending on the type of documentation. Whether it’s an initial evaluation, plan of care, or physician certification, the signature must include the full name, date, and credentials of the provider.
Handwritten signatures must be legible; however, if they are not, CMS will accept a typed name or provider-identifying information alongside the signature, or the use of a separate signature log. That log must clearly associate the provider’s printed name and credentials with the signature or initials. This becomes especially important during audits.
When a required signature is missing entirely, a proper attestation statement can be submitted. It needs to clearly include:
- The provider’s printed name
- The beneficiary’s identifying information
- Date of service
- Signature and date of the person attesting
This statement must be provided by the author of the entry and can not be used to backdate or create documentation after the fact.
Electronic Signatures
CMS continues to support and encourage the use of electronic signatures. When managed correctly, they are more secure, easier to track, and provide a reliable audit trail. EHR systems should store these securely, with authentication protocols in place to verify the identity of the signer. They should also display credentials and time-stamping, just as a written signature would.
Electronic systems also support compliance by enabling alerts, dashboards, and reminders for time-sensitive documentation, reducing the risk of human error.
Medicare Part A Certification and Recertification Requirements
For Medicare Part A, signature compliance is tightly linked with certification timelines. A physician must complete and sign the initial certification as soon as possible after admission, but no later than Day 14. This certification must:
- Confirm the need for skilled nursing or therapy
- Include a physician’s assessment
- Be signed and dated by a physician with admitting privileges or care responsibility
The first recertification is also due no later than Day 14, followed by subsequent recertifications at least every 30 days. These recerts must clearly support the CMS elements to demonstrate the need for Medicare Part A coverage. The elements include documentation of patient specific continued skilled need, an estimated length of stay, and notes on anticipated discharge planning. There’s no required form, but best practice is to use a structured recertification document within your EHR to maintain clarity and consistency.
Therapy Medicare Part B
One of the more significant updates is the relaxed requirement around initial therapy plan certifications under Medicare Part B. Starting January 1, 2025, if a written order or referral is already on file, and the therapist documents that the treatment plan was shared with the referring provider within 30 days of the initial evaluation, then the provider’s signature on the initial certification is no longer required.
However, this doesn’t remove the need for recertification every 90 days, which still requires the provider’s dated signature. While skipping the initial signature might be allowed, many facilities may still choose to obtain it as a safeguard, especially in complex cases or when physician oversight is vital to the care plan.
What to Do When a Signature is Missing: Use of Delayed Certification Forms
Triple-check meetings remain a valuable safety net to confirm that all required documentation, including certifications and signatures, is in place before submitting a claim. If a signature is missing during this review, a Delayed Certification/Recertification form can be used.
These delays must be documented thoroughly, and the reason must be credible (for example, unexpected absence of the physician or EHR access issues). CMS won’t accept delays caused by routine neglect or lack of workflow. Always include the actual certification period and have the documentation signed and dated.
Culture of Compliance: Education, EHR Optimization, and Internal Audits
The best defense against denials is a strong, proactive compliance culture. This means:
- Regular staff education on documentation and signature requirements
- Clear workflows and checklists for timely certification/recertification
- EHR tools to prompt for missing information before deadlines
- Internal audits (monthly or quarterly) to identify patterns and fix problems early
The use of a physician query is also a useful tool when entries are missing key data. These should be brief, clearly documented, and followed up within appropriate timeframes.
Supporting Physicians in Meeting CMS Signature Standards
Physicians often juggle documentation with clinical responsibilities, and many facilities struggle with missed signatures or late entries. Supporting providers through brief, direct reminders or real-time education is key.
If you’re present while the physician signs a record, encourage them to add the date immediately. If they forget, and you witness the signature, you may document your name, credentials, and the date the signature was observed. This is not a substitute for their dating the record, but it does help preserve integrity in the interim.
Quick reference guides, one-on-one coaching, and embedding compliance reminders into daily workflows can significantly reduce these errors.
Real-World Examples: Avoiding Denials with Practical Safeguards
One facility had a $10,000 claim denied due to a missing physician’s signature on a Medicare Part A recertification. The problem was caught too late to correct. Since then, they have added automated alerts to their EHR and involved physicians more directly in the documentation review process.
Another SNF flagged multiple unsigned therapy plans during an internal audit before billing. This early catch enabled staff to locate the missing signatures and prevent denials. That simple check avoided a serious financial setback.
Signature compliance is not just an administrative task. It directly affects revenue, patient care, and your facility’s credibility. With every CMS update, SNFs should prioritize education, process improvement, and EHR optimization to remain compliant. Timely, complete, and accurate signatures support a clean medical record, defensible claims, and uninterrupted care.
Staying ahead of these requirements is not always easy, but it is completely manageable with the right process in place. Use these updates as an opportunity to fine-tune your systems and invest in your teams. In the long run, that’s what keeps your patients and your facility moving forward.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services to assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
