The Importance of Physician Documentation

The absence of complete and accurate physician documentation continues to pose a concern for clinics and surgery centers. Being in compliance and ensuring accurate reimbursement depends largely on the quality of code assignments that drive prospective diagnosis related group (DRG) and ambulatory payment classification (APC) billing and payments.

However, the correct application of coded data depends heavily on physician documentation, which is not always complete and reflects services. Physicians need to document completely to ensure proper coding so billing is accurate upon submission.

In the coding world, there is a phrase "not documented not done", which means if a physician did not provide diagnosis and procedure information to determine the coding, it is not billable. Physicians need to know that coders are limited in what they can code. They are not allowed to make assumptions or interpretations and must depend on the quality of the documentation in the medical record. The physician is responsible for determining the principal and secondary diagnosis of the patient. Coders cannot assign conditions listed without physician supporting documentation in the body of the medical record.

There are procedures that a facility or physician's office can put in place to facilitate documentation compliance. Billing issues can stem from physicians who do not understand the methodology behind coding and how documentation, or the lack of, affects coding and billing. Therefore, physicians need on-going education regarding the importance of proper documentation and the impact it has upon accurate billing. Documentation reviews should be held throughout the year. Another way to maintain compliance is to have a standardized list of abbreviations and terms for use throughout your facility. Make sure there is a standard procedure and safe guards for correcting error in patient documentation entries. Share data with physicians, let them know that in order to justify medical necessity they must document severity information in all aspects of the visit.