Lack of Documentation Affects Provider Reimbursement
A lack of necessary documentation affects provider reimbursement. Remember the Golden Rule:
- All information about services performed must be documented
- If it isn’t documented, then it wasn’t performed. Reviewers do not know the services provided if there is no documentation.
- You are paid for what you document, not what you did
- Document, Document, Document!
- More is always better when it comes to documentation
- Always provide a signature attestation for missing signatures
- If a signature is missing from an order, the physician/NPP must clearly document in the medical record of his or her intent that the test and/or service be performed