Having legible notes, supporting documentation, and signatures are important to all parties involved and important in order to avoid denials.
Medical records should be:
- Complete and legible.
- Should include the legible identity of the provider.
- The date of service.
- Any amendments, corrections, or delayed entries must clearly and permanently be identified, clearly indicate date and author, and clearly identify all original content.
- Must contain signatures.
- Signatures must be clear and legible (use attestation statements or signature logs).
- Illegible documentation can have the physician’s staff transcribe it and have physician confirm it is a true and correct translation.
- If documentation is not legible and correct what should be done:
a. Explain to patient it is not covered without correct and legible documentation
b. Get the patient involved
c. Use an ABN if patient still insists and do non-assigned with the ABN
REMEMBER: If it is not documented it is not covered.
Use the US Rehab/VGM audit help site www.vgmaudithelp.com or for additional assistance contact:
800-401-3643 Peggy Walker, RN in South Carolina
888 665 6518 Ronda Buhrmester, CRT, CFm in Iowa