AAPC - Back to school
Results 1 to 3 of 3

Thread: Where is it documented that you need to document?

  1. #1
    Join Date
    Apr 2007

    Question Where is it documented that you need to document?

    AAPC: Back to School
    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.

  2. #2
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


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


    “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.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Join Date
    Apr 2007


    Thank you!

Similar Threads

  1. HPI - who can document
    By StacyGalloway in forum Family Practice
    Replies: 1
    Last Post: 09-04-2014, 05:42 AM
  2. No p.e. documented
    By cshelton1956@comcast.net in forum E/M
    Replies: 3
    Last Post: 04-24-2014, 06:43 AM
  3. ?Document Level
    By cnramsey in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 08-22-2012, 10:17 AM
  4. highlighting within document
    By huggarat2 in forum Medicare Regulations
    Replies: 0
    Last Post: 03-26-2012, 08:50 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.