Online Training Course

Prod ID: 349
Why Quality Documentation Matters

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.




57 min



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.

Jan Hailey


Jan Hailey is PMI's Director of Workforce Initiatives. She has more than 20 years of experience in healthcare administration, coding, and billing, and a passion for teaching educational programs nationwide.

Jan is the former Director of Care Management with Select Health Network, an entity of Saint Joseph Physician Network in Mishawaka, IN.  She led a comprehensive interdisciplinary team across the health system and worked closely with providers, management, staff, community, and payers to develop strategies for process improvement, gap closures, and patient experience.  To improve risk scores for the health system, Jan developed a documentation improvement and education program for the Hierarchical Condition Category (HCC). Prior to joining Saint Joseph, she served as Director of Quality, Coding, and Compliance for one of the largest health systems in Northern Indiana.

She earned a Master's in Healthcare Leadership and holds four professional certifications in medical office management, coding, billing, and compliance, and is an active member of WPS Medicare’s Provider Outreach and Advisory Group, Indiana Association for Healthcare Quality. 

This training session will inform you of what you need to know about the importance of quality documentation in medical records. 

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 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. Learn how to address and correct the top root causes identified for inadequate documentation:

  • Missing documentation to support medical necessity
  • Missing provider’s intent to order (for certain services)
  • Missing order
  • Inadequate documentation to support the services were provided or other documentation required for payment of the code
  • Inadequate documentation to support medical necessity 

Self-paced online program includes unlimited review of previously recorded instruction and the downloadable PowerPoint handout for 6 months.

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