AAPC - Back to school
Results 1 to 5 of 5

Thread: Illegible Documentation

  1. #1
    Join Date
    Apr 2007

    Default Illegible Documentation

    AAPC: Back to School
    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. #2
    Join Date
    Apr 2007


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

  3. #3
    Join Date
    Apr 2007


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

  4. #4
    Join Date
    Apr 2007


    A few interesting things to look at.


    The last question.


    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

  5. #5
    Join Date
    Apr 2007


    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.
    Jenny Berkshire, CPC, CEMC, CGIC

Similar Threads

  1. Documentation on correct documentation placement of procedure notes in the EMR
    By ashephard in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-25-2014, 03:36 PM
  2. Illegible Documentation
    By eeoo in forum Auditing General Discussion
    Replies: 3
    Last Post: 05-12-2010, 07:27 AM
  3. illegible records
    By dsmith06351 in forum Auditing General Discussion
    Replies: 1
    Last Post: 09-15-2009, 11:53 AM
  4. illegible signature
    By chandler80 in forum Diagnosis Coding
    Replies: 0
    Last Post: 11-20-2008, 06:51 AM
  5. Illegible Documenation
    By renifejn in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 07-02-2008, 07:12 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.