Wiki Question

[coder21]

If you where doing an audit and there note is not readable what would you do? Ask if for the note to be fixed or not added points to the audit?

 

[Karolina]

I would try very hard to read it and if it is absolutely impossible and nobody else can read it either I would not credit any points for the illegible parts. The final code would be derived from the legible segments of the note.
Medicare's rule says that if 3 different auditors cannot read the note it is deemed illegible.

 

[LLovett]

I use the rule of 3, and if 3 people can't read it they don't get credit for it. On a side note I found this awhile back from WPSMedicare and thought it was interesting.

"2. If documentation is requested for review and the provider's documentation is
illegible, would it be appropriate for another staff member (i.e., coder, nurse) to
interpret the documentation and submit the more "legible" form of
documentation?
Yes, that is acceptable; however, remember to submit the actual illegible documentation
initially requested with the more legible form of documentation.
REFERENCE: IOM Program Integrity Manual, Chapter 3"

Laura, CPC