Internal Medicine Coding Alert

Published on Wed Apr 17, 2013 PDF

Question:  My physician’s handwriting really is difficult to read sometimes, and I’m nervous because I’ve heard that payers are getting stricter about illegible documentation. Is he going to face penalties?

Wyoming Subscriber

Answer:  You’re wise to show concern, because your physician could actually have problems with payers in the future if they cannot read his notes. Stress the importance of legible notes to your provider. You may even want to suggest that he print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility.

Many coders shake their heads when they hear that some physicians maintain incomplete notes, and that auditors ask those physicians for money back since their documentation didn’t support the codes they billed. But have you ever thought that writing illegibly could make you qualify for CMS’s interpretation of incomplete notes?

“When determining the medical necessity of an item or service billed, Medicare’s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,” CMS says in MLN Matters article SE1237. “Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS [fee-for-service] claim payment denials.”

Despite the old stereotype of physicians’ handwriting being impossible to read, your physicians should ensure that their documentation is legible — not only by staff members familiar with it — but also by anyone who might be reading the notes.

To read the MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1237.pdf.