Dealing with Legibility Issues and Challenging Handwriting?

Dealing with Legibility Issues and Challenging Handwriting?


by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

We’ve all seen this:

Handwritten and illegible entries in the patient health record are an important consideration in the query process. It is important to decide when bad handwriting rises to the level of a physician query.

In general, if your inability to read certain documentation is clearly going to impact your ability to assign an accurate code, then you need to consider a query.

From a quality of care and risk management perspective, illegible entries can:

  • Cause miscommunication among clinicians about the patient’s condition
  • Result in improper care and cause serious patient injury
  • Raise questions of legal viability
  • Easily lead to poor data quality and incorrect reimbursement
  • Cause data collection, billing and reporting errors

 

Next:
Format Of A Physician Query, Developing The Statement At Issue, And The Importance Of Hospital Policies And Procedures Related To The Physician Query Process.


References:

  • AHIMA Practice Brief: Managing an Effective Query Process, 2008
  • AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
  • AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010

Certified Coding Specialist (CCS) Exam Review: CCS for CDI
Prepare to sit for AHIMA’s Certified Coding Specialist (CCS) exam with this online, self-paced, interactive and comprehensive review. Includes ICD-10-CM, ICD-10-PCS, and CPT coding practice; covers reimbursement methodologies, data quality, regulatory issues, and compliance; and provides valuable study and test-taking strategies. Learn more here.

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

Comments are closed.