Urology Coding Alert

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

Wyoming Subscriber

Answer: You should stress the importance of legible notes to your urologist. 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 a medical record (EMR) system to ensure legibility.

Many coders shake their heads when they hear that some physicians maintain incomplete notes. Often auditors ask those practitioners for money back because their documentation did not support the codes billed. However, have you ever considered that incomplete documentation may actually be a result of illegible 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.