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Where is it documented that you need to document?

  1. #1
    Question Where is it documented that you need to document?
    Medical Coding Books
    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
    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, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

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

  3. #3
    Thank you!

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