Documentation is a vital information in the medical health record of each practice. Part of the job of a coder and biller is to make sure that the submitted claims are supported by the physicians' documentation. If the documentation does not support the claim and the error is discovered, the provider is liable for the incorrect payment and possibly additional repercussions (consequences).
Do not bill services that are not supported by documentation. If the health care provider doesn't state a procedure in his dictation (in his operative report) or note in the physician's notes, regardless of how obvious it may seen, it was not done. When in doubt or faced with incomplete documentation, remember: "If the doctor didn't say it, it wasn't done."
When the documentation is missing or ambiguous, it's the responsibility of the coder to clarify with the physician. Although some physicians become defensive or irritated when coder ask questions about the missing documentation (hope the provider will reconsider or else they will face some problems with their financial health and practice), but those who understand the questions can maximize their reimbursement and minimize suspicious activity in their practice will gladly amend the documentation to clear up the problem as soon as possible.
The importance of consistent, complete documentation in healthcare cannot be overemphasized. Without such documentation accurate coding cannot be achieve. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
FYI: In the view of the payer, a service that was not documented was not done and cannot be coded and billed. To bill for undocumented services is fraudulent.
Benefits of Proper Documentation
1. Improves compliance
2. Improves patient care
3. Improves clinical data for research and education.
4. Protects the legal interest of the patient, facility and physician.
5. Enables proper reimbursement for services performed.
6. Achieves accurate case mix index by correctly coding from proper documentation.
Important:
Do not alter information other than address or insurance information in a patient record.
Do not add a diagnosis and a procedure code that is not documented in the patients record.
The following characteristics are associated with patient record documentation in all healthcare settings:
1. Documentation should be generated at the time of service or shortly thereafter.
2. Delayed entries within reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, correction of errors, addition of information not initially available, and when certain unusual circumstances prevent documentation at the time of service. Delayed entries cannot be used to authenticate services or substantiate medical necessity for the purpose of the reimbursement.
3. The patient record cannot be altered. Doing so is considered tampering with documentation. This means that errors must be legibly corrected so that a reviewer can determine the origin of the corrections, and the used of correction fluid is prohibited.
4. Corrections or additions to the patient record must be dated, timed and legibly signed or initialed.
5. Patient record must be legible.
6. Entries should be dated, timed, and authenticated by the author.
