Documentation supports reimbursement; therefore, you must be certain that the information is straightforward and accurate, and that it “flows” in chronological order. Be mindful that clinical documentation also service as legal documentation.

Some of the most common deficiencies found in documentation are:

  • Lack of patient signature, such as:
    • ABN not signed
    • Financial policy not signed
  • Physician orders/scripts missing, incomplete, or not current, and/or illegible
  • Missing pages within the documentation
  • Missing or wrong date of service
  • Missing and/or improperly reporting CPT®/HCPCS Level II modifiers
  • Missing clinical significance/medical necessity for lab orders
  • Failure to document procedures
  • Detail missing from the patient encounter

Any of the above may cause a claim to be downcoded or denied, lead to retraction of the previous payment, or cause the practice to be placed on prepayment review.