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Illegible Documentation

  1. #1
    Default Illegible Documentation
    Medical Coding Books
    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?

  2. Default
    I am currently conducting an audit for a gastroenterologist. All notes are just scribbled notations from the encounter. I have the same question. From what I can decifer, his scribbles don't support the level he billed. What do I do?

  3. #3
    North Carolina
    c. Documentation.

    Timely, accurate and complete documentation is important to clinical patient care. This same documentation serves as a second function when a bill is submitted for payment, namely, as verification that the bill is accurate as submitted. Therefore, one of the most important physician practice compliance issues is the appropriate documentation of diagnosis and treatment. Physician documentation is necessary to determine the appropriate medical treatment for the patient and is the basis for coding and billing determinations. Thorough and accurate documentation also helps to ensure accurate recording and timely transmission of information.

    i. Medical Record Documentation. In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided. The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider). Examples of internal documentation guidelines a practice might use to ensure accurate medical record documentation include the following:
    The medical record is complete and legible;

    Page 7

  4. #4
    When I audit records and the documentation is illegible, I ask the provider (or someone who can read the writing) to transcribe the documentation. Many carriers allow illegible documentation to be transcribed for carrier audits. The transcribed record should be reviewed with the written record to ensure that nothing was added to the transcribed record.
    Jenny Berkshire, CPC, CEMC, CGIC

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