Gastroenterology Coding Alert

Question: One of our gastroenterologists is driving the coding department crazy. Each operative report he hands in is impossible to read - his notes are a jumble of illegible letters, and most of his CPT and ICD-9 codes are unidentifiable. How can I tactfully convince the doctor that his penmanship needs to be clearer?

Alabama Subscriber

Answer: From the sound of it, this doctor's wayward writing is throwing your office out of whack. He may not realize what a drag his penmanship is on the productivity of the practice.
 
Telling the physician the ugly truth is an option, but be nice: You might consider saying something like, "Doctor, we are all having a bit of trouble reading your penmanship, and it's slowing us all down when we are processing your notes." That may be all it takes to get the good doctor writing more legibly.
  
If the nice tactic doesn't work, tell your gastroenterologist that the office could get fined for his writing. Have him read this true story told by Susan Manning, JD, of the Wisconsin Medical Society at April's American Academy of Professional Coders (AAPC) conference
in Atlanta:
  
An auditor from the Centers for Medicare & Medicaid Services Office of the Inspector General entered a Pennsylvania medical office and pulled some patients' files at random, Manning said.
 
The auditor asked a physician assistant if he could read the doctor's notes; he couldn't. The auditor then asked a receptionist if she could read the doctor's notes; she couldn't. Finally, the auditor asked a coder if she could read the doctor's notes; she couldn't, either.
 
Result: "No one could read the notes, so he [the OIG auditor] fined the office," Manning said. And the office got off easy, even though they lost some dough. If a patient ever sued the doctor's office, illegible documents could spell trouble.