Wiki Illegible Documentation

[eeoo]

A provider's documentation for services is completely illegible. Other than the 95 and 97 Guidelines, are there any other locations where it is cited that documentation must be legible? Any other experiences with illegible documentation?

 

[kmonte]

It is also noted in the NAMAS curriculum. Whenever I have a provider give me grief about anything, I pull out the book.

 

[eeoo]

Is that available to anyone or do you have to belong to NAMAS for that information?

 

[LLovett]

A few interesting things to look at.

http://www.wpsmedicare.com/part_b/education/2009_0615_emfaqdoc.pdf

The last question.

http://medicalrecordrights.georgetown.edu/stateguides/nj/nj.pdf

I received a copy of my medical record, but I can’t read my doctor’s handwriting. Does
my doctor have to give me a copy that I can read?
Yes. Under New Jersey law, if a doctor or other health care professional gives you a
copy of a medical record that you can’t read because it is illegible or was written in a
language other than English, they must provide a typed copy in English. The health
care professional cannot charge you for this transcription. This rule does not apply to
hospital records.

I'm in Michigan but I thought the NJ info was very interesting. There are several other articles out there talking about the risk from a medical/legal standpoint as well.

Laura, CPC, CPMA, CEMC

 

[j.berkshire]

My Medicare carrier in Ohio, Palmetto GBA, has published a response to this question on their FAQ page.

Question: If Medicare determines that my records are not legible, will you treat this as if no documentation is available?


Answer: Yes. Medicare will accept transcribed notes in addition to copies of the original. If a provider feels that his/her notes may not be readable by the carrier staff, he/she is advised to translate these notes prior to submitting them to the carrier for review. The carrier must at least be able to tell that they indeed only translate the original document and that no enhancements to the document have been made. If we cannot read the notes, the service will be denied.