Lack of Documentation Affects Provider Reimbursement

Published 01/13/2022

A lack of necessary documentation affects provider reimbursement. Remember the Golden Rule:

  • All information about services performed must be documented
  • If it isn’t documented, then it wasn’t performed. Reviewers do not know the services provided if there is no documentation.
  • You are paid for what you document, not what you did
  • Document, Document, Document!
  • More is always better when it comes to documentation
  • Always provide a signature attestation for missing signatures
  • If a signature is missing from an order, the physician/NPP must clearly document in the medical record of his or her intent that the test and/or service be performed

Reference: Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3 (PDF).