Watch for Common Documentation Deficiencies
- By John Verhovshek
- In Billing
- May 6, 2015
- 1 Comment
Documentation supports reimbursement; therefore, you must be certain that the information is straightforward and accurate, and that it “flows” in chronological order. Be mindful that clinical documentation also service as legal documentation.
Some of the most common deficiencies found in documentation are:
- Lack of patient signature, such as:
- ABN not signed
- Financial policy not signed
- Physician orders/scripts missing, incomplete, or not current, and/or illegible
- Missing pages within the documentation
- Missing or wrong date of service
- Missing and/or improperly reporting CPT®/HCPCS Level II modifiers
- Missing clinical significance/medical necessity for lab orders
- Failure to document procedures
- Detail missing from the patient encounter
Any of the above may cause a claim to be downcoded or denied, lead to retraction of the previous payment, or cause the practice to be placed on prepayment review.
John Verhovshek
John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
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Can you tell me where do I find the guidelines regarding smoking documentation?
I had a provider who listed smoking in his assessment plan but he did not state anything in his note concerning the smoking and I was told that I should have not coded it. I was also told that if the provider list any chronic condition in his assessment plan to code. I am a little confused why the auditor count that as an error. Could you please help.