Physicians may not understand the true impact their documentation has on the reimbursement for services they render. Documentation is the written record of what has occurred and physicians must tell the story of the encounter through the documentation in the patient’s medical record. If it isn’t documented, it wasn't done.
Physician documentation is like a story problem and the codes submitted on the claim form are the answer to the story problem. Documentation must equal the codes submitted.
Health plans may perform routine pre- or post-payment reviews of submitted claims. The medical record documentation is scrutinized to be sure the physician documented what was billed.
The Michigan State Medical Society developed a new Coding Alert, titled "The Impact of Medical Record Documentation and Coding on Reimbursement." This new alert highlights the importance of physician documentation which highlights documentation health plans look at, how medical record documentation impacts reimbursement, and newly introduced E&M services which may increase revenue opportunity. To download the new Coding Alert, please click here (member login required).