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Illegible Documenation

  1. Default Illegible Documenation
    Medical Coding Books
    Does anyone have any source which talks of illegible documentation? Is there some kind of rule where if 3 or more people cannot read a note it is considered unbillable?


  2. #2
    North Carolina
    "Is there some kind of rule where if 3 or more people cannot read a note it is considered unbillable?"

    Personally speaking, I have never read a rule/reg requiring this. If documentation is illegible, this will have a direct effect on the reviewer's ability to make a fair determination on the overall review process. If documentation is illegible, it's impossible to support medical necessity for the services and define what service was performed. I've had repeat offenders for this very problem and dictation was, normally, the solution. The provider still needs to review what actually prints out on his dictated note. It really boils down to the old saying...."If it's not documented, it wasn't done". If I can't read it, then it's as good as not documented in my book.
    Rebecca CPC, CPMA, CEMC

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  3. #3
    I had one case where the insurance denied the claim saying they could not read the doctor's notes. We ended up having to type out the note and he then signed it. We sent both the handwritten notes and the typed notes to the ins and we got paid. If the doctor's see this is creating additional work, maybe they'll get better .

    Zaida, CPC

  4. Default
    Frequently your carriers or intermediaries will have policies regarding illegible documentation.

  5. #5
    Louisville, KY
    When I worked on the payer side (in med review), I made an honest, concerted effort to unveil the mysteries of illegible documentation; however, to mirror what's been said here, if after my best effort I could not determine anything, then it was "nothing." Keep in mind that I tried to be fair with this. I had co-workers who simply felt that clear documentation was a requirement and would not take the pains I did. They simply denied the service as "illegible".

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