General Surgery Coding Alert

Question: I have heard that payers are cracking down on illegible provider documentation. Could my surgeons actually be penalized for poor handwriting?

Wyoming Subscriber

Answer: Yes, it’s true! You should stress the importance of legible notes to your provider, because he may, indeed, have problems with payers in the future if his notes cannot be read. You may even want to suggest he print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility.

No panacea: Having an EMR does always make note legible. If there are typos or missing words, it may still be impossible to figure out what service was performed. Physicians should always review their documentation before signing it.

What’s at stake: Many coders shake their heads when they hear that some physicians maintain incomplete notes, and that auditors ask those practitioners for money back since their documentation didn’t support the codes they billed. But have you ever thought that writing illegibly could make you qualify for CMS’s interpretation of incomplete notes?

"When determining the medical necessity of an item or service billed, Medicare’s review contractors must rely on the medical documentation submitted by the provider in support of a given claim," CMS says in MLN Matters article SE1237. "Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials."

Despite the old stereotype of physicians’ handwriting being impossible to read, your practitioners should ensure that their documentation is legible — not only by staff members familiar with it, but also by anyone who might be reading the notes.

To read the MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1237.pdf.