7 Criteria to Follow for Clinical Documentation Improvement (Part 1): Legibility

Posted: Mar 05 2015


Clinical documentation is the foundation of every patient medical record. All persons who document in records should meet clinical documentation standards. The record supports the severity of the patient’s condition, assessments and evaluations leading to diagnoses and treatment management. Without strong documentation, it becomes difficult to support the medical necessity of services provided, opening the door for additional information requests, down coding, or denial of services.

Additionally, in situations where legal action has been initiated, the record will provide the support needed by the provider to justify management and billing. If the record contains vague and ambiguous language, or is missing key information, this advantage is significantly compromised, and may lead to a costly negative outcome.

Coders need high quality documentation to determine coding quality and accuracy, and cannot assume a diagnosis unless documented by the provider. Every regulatory agency is placing heavier emphasis on clinical documentation. As the industry moves toward value based medicine and blended payments, rather than fee-for-service, providers must become more focused on the documentation. The advantage really is in the details.

Criteria #1: Legibility

Legibility is included as a requirement by every regulatory agency. We are in an era where patients are increasingly demanding transparency in their medical record. HIPAA has given patients the right to see his or her own medical record and request clarification of any entries that are illegible. Although electronic health records have reduced the amount of hand written record entries, there are still risks when entries are rushed or careless.

When your documentation is requested by payers, proofread it before submitting the information. If entries are illegible and the payer is unable to determine with certainty the meaning of the information, they may default to denial of the claim.

In situations where audits, investigations or other types of legal action has been initiated, the legibility of the record and its supporting rationale of the patient’s condition and management will be crucial in determining the outcome.


About the Author

Ms. Dorothy Steed, CCS, CDIP, CPC-H, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, has 38 years of experience in both hospital and physician billing, coding, reimbursement and claims management, specializing in Medicare requirements. Ms. Steed is credentialed in medical coding, compliance, utilization management, utilization review, medical auditing, clinical documentation improvement and patient accounts.


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