May 26, 2023 | By Stephanie Allard, CPC, CEMA, RHIT
Most of us, if not all of us, have heard the statement, “If it isn’t documented, then it wasn’t performed.” While I know this is often the perspective of payors, I cringe when I hear this, thinking about all the providers that I work with and the fact that it may not be a true statement that the procedure was not done.
I recently was having a conversation about this with a good friend who is also in the medical coding industry. She was working through a scenario where a surgeon was documenting only the name of the procedure in the heading of an operative report and no details were listed in the body of the report. She was being questioned and pushed by leadership to code from the heading only (I can hear you all gasping now!) after they were made aware that no details were noted and were told this is against guidelines. I myself have seen this and it can be frustrating when the organization or provider is failing to see the large compliance risk that exists.
I come across this situation often in my own surgical audits and in the office setting. How many times have you seen an order for a procedure or a statement that it was “performed,” but no detail exists to help us navigate the CPT code index and validate the appropriateness of the code the provider would like to bill?
As we were discussing, I came upon guidance that was published by Palmetto GBA on 1/13/2022 that lays it out for all of us that need to communicate this to our providers and/or organization leadership. On the Palmetto website they list the “Golden Rule” regarding how lack of documentation affects provider reimbursement.
“A lack of necessary documentation affects provider reimbursement. Remember the Golden Rule:
- All information about services performed must be documentedIf it isn’t documented, then it wasn’t performed. Reviewers do not know the services provided if there is no documentation.
- You are paid for what you document, not what you did
- Document, Document, Document!
- More is always better when it comes to documentation
- Always provide a signature attestation for missing signatures
- If a signature is missing from an order, the physician/NPP must clearly document in the medical record of his or her intent that the test and/or service be performed
Reference: Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3 (PDF).”
All the items listed above are great reminders for documentation requirements. One that stands out to me is the 3rd bullet point “You are paid for what you document, not what you did.” This again can sound harsh, but let’s think about this. Each CPT code has a description and, at times, specific guidelines, that show what is required to have been performed in order to bill for the service. Documentation is the evidence that we have as a coder/auditor to validate the performance of a procedure. It is important for all of us to remember that we cannot make assumptions about a scenario and validate a service based on what we know is typically performed. As a coder/auditor working internally for an organization, you are not doing the provider any good by coding based on assumption. It should be our goal for the documentation and code selection to meet compliance on the first round of an external audit. Knowing a scenario would have to be defended could be costly and is highly problematic from the compliance perspective.
With the direct access patients now have to their medical records and the external auditing environment that we currently exist in; can the organization or provider afford to spend the time and money that it takes to defend what was done that is nowhere seen within documentation? Not only do we need to consider coding/billing, the provider also needs to be thinking about the level of support they have for potential malpractice accusations.
This can be a point of frustration from the provider perspective. As auditors, we are aware of the guidelines that are to be followed. It is common for me to get comments from a provider that they are doing the best they can and the audit feedback is just one more ask and they do not have the capacity to keep adding on more work. I encourage you as you read this to think through solutions for your providers. Do not just present the guidelines and point out the problem; work to be a part of the solution. Help bring your providers to implement the changes to their documentation and attempt to do that in as painless a way as possible!
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
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