Forum - Questions & Answers

Jul 9th, 2015 - PatriciaT

documentation

is there a statute that delineates a timeline of when a document has to be complete? in other words, can charges be submitted legally if documentation to support the charge is not complete?

Jul 9th, 2015 - ginasn 12 

re: documentation

Everything that I have ever been taught boils it down to, "If there is no documentation, then it wasn't done." Carrying this through to actual coding, charges for encounters cannot be processed for payment if there is no documentation to support the charge. What if you get audited? What if the insurance company comes back and requests records? You could be opening up your firm for a lot of problems by posting charges with no documentation.
Can you try to come to an agreement with your provider that you will post the charges, maybe place them on hold so they do not go out the door, and you will release them when the documentation comes in and you can check your CPT® and ICD-9?



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