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