Wiki Where is it documented that you need to document?

[swebco]

We have all said "If it isn't documented, it wasn't done." I need the Federal Register/ Medicare Manual/ Guidance, anything that lays this out in legalize. While this is a common quote, I am having difficulty locating the directive in the manual.

Also, if you have the supportive citation for not billing until you have documentation in place--I will kiss you, or barring that, I will tell everyone you are the smartest individual on the face of the planet.

I used to have this I know I did, I just can't find it and it's driving me crazy. Thanks so much for your help.

 

[Pam Warren]

This is in the CMS E&M guidelines, page 4:

http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

GENERAL PRINCIPLES OF EVALUATION AND MANAGEMENT DOCUMENTATION
“If it isn't documented, it hasn't been done” is an adage that is frequently heard in the
health care setting.
Clear and concise medical record documentation is critical to providing patients with
quality care and is required in order for providers to receive accurate and timely
payment for furnished services. Medical records chronologically report the care a
patient received and are used to record pertinent facts, findings, and observations about
the patient's health history. Medical record documentation assists physicians and other
health care professionals in evaluating and planning the patient's immediate treatment
and monitoring the patient's health care over time.

Hope this helps.

 

[swebco]

Thank you!