Documentation is Part of Your Treatment It’s easy to get busy in a practice, not just with patients, but with the seemingly never-ending paperwork. As frustrating as it may be, it’s a part of the treatment to document the visit. We suggest that you consider setting your own practice standards for documentation timeliness in your…
If it’s Not Documented, It Didn’t Happen Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature authenticating the note. Unless the documentation for a service is completed, including signature, a provider cannot submit the service to Medicare. Medicare states if the service was not documented, then it…
Download Reference Documents The documents found here are references from the profession that outline standards set for documentation and coding. Download, review and save them, as appropriate for your continued reference. AHIMA Standards of Ethical Coding Sample Medical Review Policy
Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) When it comes to oversight of coding and documentation compliance on the Federal level, the top of the totem pole is the OIG for HHS. The mission of the OIG is to protect the integrity of the Department of Health &…
Tracking Down Your Payer’s MRP When billing any third-party payer, you must be familiar with their Medical Review Policy (MRP). They are usually found within the medical policy section of the carrier’s website but may be made available to clinics through a provider portal. Look for terms such as Clinical Coverage Bulletin, Provider Tools, Reimbursement…
Standardized Documentation and Coding Guidelines It would be wonderful if there were a magic button to press to know exactly what documentation guidelines to follow when performing self-audits and evaluating your compliance. Unfortunately, this isn’t so. Documentation standards are often open to interpretation, whether from a licensing board, a payer, or a malpractice attorney. For…