Not Documented, Not Done: Medicare Myth or Rule?

December 29th, 2015 - Codapedia Staff
Categories:   Audits/Auditing   Claims   Documentation Guidelines  

After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like other “urban myths.”
In a 2008 article that retains relevance to coders today, Michael D. Miscoe, CPC, CHCC, noted that thorough documentation has become the de facto requirement to support claims for reimbursement by government and private payors. But an objective investigation into Medicare rules and their supporting statutes won’t support the common belief that “not documented—not done” is a legitimate rule, he argued in the Journal of Medical Practice Management.

By a strict interpretation of Medicare rules, lacking documentation does not render a medical service noncompensable. The Social Security Act itself mandates no payment “unless there has been furnished such information as may be necessary in order to determine the amounts due” (42 U.S.C. §139(e). A “clean” claim with the proper ICD-9 and HCPCS codes and appropriate fees fulfills this requirement.

Recent case law further supports this conclusion: The federal court ruled against the U.S. in a False Claims Act (U.S. ex rel Sikkenga v. Regence Blue Cross Blue Shield of Utah) case and reasserted that the Medicare statute only imposes an information requirement and “not a particular content requirement.”

Not So Fast!

A wary practice manager may want to hide this information from certain providers within his or her organization. Many group practices include physicians who reluctantly scrawl the briefest of “notes” for office encounters—sometimes inadequate for recording and communicating what happened during the visit. They sometimes hide behind a cavalier attitude summed up with, “ . . . I know what I did!”

Just because a strict interpretation of the law may extract some of the teeth from “not documented—not done,” that doesn’t reduce the need for good, accurate, and thorough documentation. Quality patient care includes maintaining a record that allows anyone with a legitimate reason to pick up the chart to understand the patient’s history of diagnosis and treatment.

Average physicians see thousands of patients each year. Regardless of claims to the contrary, a documentation-averse provider seldom possesses memory skills capable of recalling unwritten details years later.

Although the OIG’s own audit manual names documentation as only one of four types of “evidence” to determine whether a particular service was performed and properly reimbursed, why put auditors, your practice, and yourself through substantial anguish to prove your case? Doesn’t it make much more sense to document well?


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association