tci Outpatient Facility Coding Alert - 2013 Issue 5

Reader Question: Penalties Could Be Coming for Illegible Documentation

Question: My physician’s handwriting really is difficult to read sometimes, and I’m nervous because I’ve heard that payers are getting stricter about illegible documentation. Is he going to face penalties? Wyoming Subscriber Answer:  You’re wise to show concern, because your physician could actually have problems with payers in the future if they cannot read his notes. Stress the importance of legible notes to your provider. You may even want to suggest that he print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility. Many coders shake their heads when they...

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