Why Quality Documentation Matters
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About this program
If you work with provider claims, then you have probably heard the phrase, “If it isn’t documented, it wasn’t done.” The importance of quality documentation in the medical record cannot be overstated. It protects patient safety, and coordination of care between providers and across the healthcare continuum.
Correctly coded claims will ensure appropriate payment and reduce denials of claims and protect the provider against accusation of fraud and abuse. It involves the inclusion of complete, accurate details of each encounter to support the integrity of the claim and proper reimbursement from federal and other third-party payers.
The False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. Yet, incomplete/incorrect claims continue to be flagged in audits for everything from missing documentation to support medical necessity, missing order, inadequate documentation.
A 2020 Medicare Fee-for-Service Supplemental Improper payment Data report found 74.1% of the Part B improper payments were due to missing/inadequate documentation meaning something was incomplete or missing from the documentation submitted with a claim.*
Attend this important webinar to learn how to address and correct the top root causes identified for inadequate documentation: