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Watch for Common Documentation Deficiencies

Watch for Common Documentation Deficiencies

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
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About Has 570 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

No Responses to “Watch for Common Documentation Deficiencies”

  1. Delliah Walker-Tall says:

    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.