December 11, 2012

What’s “Chicken Scratch” Got to Do with ICD-10?

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The online Urban Dictionary defines “chicken scratch”— also known as illegible medical record documentation in the healthcare industry—as follows: “Incredibly messy handwriting that is nearly impossible to read. Usually the only person who can read it is the person that wrote it. Sometimes not even they can read it after a while. The writing looks like the footprints and/or scratches chickens leave in the dirt hence the name.”

 

The exact opposite of chicken scratch is “legible” documentation—a goal that healthcare managers may want to incorporate into their physician-education plan. Although being able to read documentation always has been important, it will be particularly so when ICD-10 comes around because the more specific the documentation, the more specific the code assignment and the better the reimbursement. Coding professionals who cannot read certain words or phrases may disregard them, which may result in down-coding, and, of course, lower payment.

Incomplete, hard-to-read documentation is not new, as noted in one of the American Health Information Management Association’s (AHIMA) practice briefs written by Barbara Glondys.  In “Ensuring Legibility of Patient Records,” Glondys calls legibility a “resource drain” (Journal of AHIMA 74, no.5 [May 2003]: 64A-D).

She writes: “The illegibility of entries found in patient records…has long been a challenging issue for HIM professionals. Illegibility poses serious risks to patient care, drains valuable healthcare resources, jeopardizes optimal reimbursement, and carries potentially disastrous legal ramifications for healthcare organizations.”

 

Glondys also points out the following: “The time and talent of clinicians and allied healthcare professionals could be better spent delivering patient care than clarifying illegible entries. Often, readability issues trigger a series of unsuccessful telephone calls to obtain clarification from the author.

Significant time can be spent by any number of professionals polling coworkers, discussing and guessing what an entry might say. Nurses spend much time clarifying handwritten orders. Many coder queries involve clarification of record entries before accurate codes can be assigned, resulting in delayed submission and billing. …

When coding practices are compromised by inability to read supportive documentation of symptoms, conditions, and delivered treatment, case mix index and reimbursement [are] harmed.”

CMS Revisits Legibility

In response to the upcoming push to educate physicians and other documenting providers (like nurses, therapists, etc.) about the need for increased specificity, the Centers for Medicare & Medicaid Services (CMS) recently issued an article highlighting the importance of legible documentation. In SE1237, CMS says that many claim denials occur because providers or suppliers do not submit sufficient documentation to support the medical necessity of the service or supply billed. Not only should the clinical notes be legible but also the identity of the provider and the date of service.

In the Medicare Benefit Policy Manual (Chapter 2, Section 30), CMS adds to the above, saying that progress notes and treatment plan should be “legible and complete, and should be promptly signed and dated by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished.”

 


 

It goes without saying that legibility applies to all documentation of each patient encounter, which includes, according to Medicare guidelines:

  • Reason for encounter and relevant history
  • Physical examination findings and prior diagnostic test results
  • Assessment, clinical impression, and diagnosis
  • Plan for care.

In addition, says CMS, the rationale for ordering diagnostic and other ancillary services should be easily inferred, If not documented. Appropriate health risk factors, and the patient’s progress, response to changes in treatment, and revision of diagnosis also should be documented clearly.

There also are a few other rules, which CMS calls “widely accepted recordkeeping principles,” related to medical documentation. For example, providers should clearly and permanently identify any amendments, corrections or addenda as well as the provider who authored them. In addition, all original content should be clearly identified but not deleted.

For medical-review purposes, Medicare requires that services provided or ordered be authenticated by the author via either a handwritten or electronic signature. To determine the identity of the author of a medical record entry, review contractors will consider evidence in a signature log or attestation statement. If the signature is missing from an order, review contractors will disregard the order during claims’ review—that is, they will proceed as if the order was not received. Signature attestations are not allowed for orders, says CMS.

 

Policies, Procedures, and Education Required

In her AHIMA practice brief, Glondys summarizes many of the steps that providers must take to resolve what appears to be a simple problem that will never go away. She says, for example:

  • Solicit the support of top leadership for tackling this issue.
  • Develop and publish policies and procedures for illegible entries in all clinical areas of the organization or strengthen existing ones.
  • Provide mandatory education on the importance of patient documentation. Glondys says, “Some HIM departments have gone so far as to mandate handwriting lessons for chronic offenders.”
  • Encourage the use of electronic records, dictated reports and other alternatives to handwritten documentation.
Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.