Palmetto GBA: when a doctor’s notes are not readable

Published: October 15, 2015

Palmetto_rgb_webWe all know the joke: if you have poor penmanship, you should become a doctor. 

Unfortunately, poor penmanship on patient notes and records can lead to claim denials, because if Medicare can’t read what the doctor wrote, we can’t know if the services were reasonable and necessary and meet all guidelines for coverage.

Medicare requires that the patient’s medical record be complete and legible, and it should include the readable identity of the provider and the date of service. With the inception of electronic records (the likely reason your doctor is now toting around a laptop computer), issues such as this are declining. However, they still present a problem when a claim is subjected to medical review.

What a doctor can do about this issue (if they have illegible handwriting):

  1. Have notes transcribed and then electronically signed by the doctor, when necessary
  2. Add amendments/corrections and delayed entries (only when needed) into medical documentation in the following way:
    •     Clearly and permanently identify the changes or corrections
    •     Clearly indicate the date and author of these changes or corrections
    •     Do not delete the original content in the record
  3. Provide an acceptable handwritten signature that meets Medicare guidelines.  These guidelines allow Medicare to look at the records and consider a ‘signature log’ or ‘attestation statement’ that identifies the author of the record, and there are specific ways a doctor who signs their name in a ‘scribble’ can meet the signature requirements.  These specific ways are identified on the CMS website, as well as the Palmetto GBA website for providers. If your doctor needs to know more about these methods, we encourage them to call our Provider Contact Center at 888-355-9165.

What you can do about the issue:

  1. If a claim denies due to illegible records, and your Medicare Summary Notice (MSN) indicates that you owe $0.00, do not pay your doctor for the service. If your doctor insists that you pay for a service in this situation (when the MSN says you don’t owe anything), call our Beneficiary Contact Center at 800-833-4455.
  2. If a claim denies and your MSN shows that you owe $0.00, it is not necessary to file an appeal. You can still file an appeal because it is your right to do so; however, you are not required when you are not liable.

If you have any questions about your Railroad Medicare coverage, please call our Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. We encourage you to sign up for email updates. To do so, click ‘E-Mail Updates’ on the top of our beneficiary website at www.PalmettoGBA.com/rr/me  to start the process. 

We also encourage you to visit our Facebook page at www.Facebook.com/MyRRMedicare.