Ophthalmology and Optometry Coding Alert

Question: I have heard payers are cracking down on illegible provider documentation. My provider’s handwriting really is difficult to discern sometimes. Is he going to face penalties?

Wyoming Subscriber

Answer: You should stress the importance of legible notes to your provider. 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.

Alternatively, a good template might serve him well as long as it is used properly. Templates also help physicians to remember to document all the work they perform instead of just what is considered clinically pertinent. But, again, proper use of the template is essential, and your ophthalmologist should consult with an E/M compliance auditor to make sure he is completing the form accurately.

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. This is especially true for medical and legal reasons as well.

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