Practice Management Alert

Question: I have heard payers are cracking down on illegible provider documentation. My provider’s handwriting really is difficult to discern sometimes. Is he going to face penalties? Wyoming Subscriber Answer: You should stress the importance of legible notes to your provider. He may, indeed, have problems with payers in the future if his notes cannot be read. You may even want to suggest 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 practitioners 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 [...]