Authentication of Reports
Authentication of Reports Question and Answers
1. Which reports are required to have authentication?
All radiology reports must be signed by the radiologist or practitioner that performs and/or interprets radiology procedures. This is explained in the Code of Federal Regulations document, 42 CFR, section 482.26, Condition of participation: Radiologic services.
2. Can one radiologist sign another’s report in their absence (i.e. on vacation, sick)?
No. As referenced above, all radiology reports must be signed by the radiologist/practitioner that performs and/or interprets radiology services. In 1998, the ACR commented to the Centers for Medicare and Medicaid Services (CMS) that under certain instances a radiologist should be able to sign a colleague’s report in their absence and that before filing a claim; the interpreting physician must sign off on the report.
Specifically, the ACR recommended to CMS that if the interpreting physician is unavailable for authentication then a colleague should be permitted to authenticate/sign the report in an effort to reflect the balance between the need to provide timely clinical information and to ensure the accuracy of the information. In this scenario, the colleague assumes responsibility when signing off on the other physician’s report. For completeness of reporting, once the originating physician returns he/she should initial next to the colleague’s signature. However, CMS has not accepted ACR’s recommendations and still requires that the radiologist or other practitioner sign their own reports. Signing a colleague’s report also could expose the “proxy” signer to risk of being named in a lawsuit involving a patient’s treatment.
ACR recognizes that the rule may impede transmitting reports timely to referring physicians but urges its members to comply with it.
3. Can I use an electronic signature to sign my reports?
Yes, an electronic signature can be used to sign reports if it can be demonstrated that the physician is the only one who has access to his/her own signature. According to 42 Code of Federal Regulations (CFR), section 482.25 (ii), published by CMS, “authentication may include signatures, written initials or computer entry”. The organization providing the ability to use an electronic signature should have verification methods in place to verify accuracy of the entry, such as pass codes and encryption. These guidelines can be viewed on the CMS website page for Electronic Signature Standard .
4. Are teaching physicians required to sign and authenticate the residents’ reports?
According to CMS when a teaching physician reviews an image, such as an x-ray with a resident, a note should be made in the report indicating that the teaching physician viewed the image with the resident and agreed with the interpretation. Before a claim can be submitted to Medicare for payment, the report must have the signature and a statement of agreement with the interpretation from the teaching physician. Please click here to access the ACR’s article on this topic, titled “HCFA Agrees on Proxy Signature for Teaching Physicians”.
For additional information on teaching physicians, please refer to the Teaching Physician’s Q&A. (Future Link).