Have your billing documentation at the ready

Even though most claims are paid without any documentation required, it's important to have the paperwork available just in case the payer asks for it.

By Julie A. Jacob, AMNews staff. Aug. 20, 2001.

Although commercial insurers and Medicare usually pay claims without asking for additional documentation to support the level of coding, it's important to have that documentation available, say medical claims coding experts.

While most physicians are well aware of the need to thoroughly document their services, it's even more important now, especially for Medicare and Medicaid patients, said Crystal S. Reeves, a principal with The Coker Group, a health care consulting firm in Roswell, Ga.

"The big concern now is that Medicare and Medicaid have targeted documentation as one of the areas they are going to be reviewing," said Reeves. "So if your documentation doesn't nearly support what you are billing, that could trigger an audit."

Many times, a physician is actually providing more services than they are documenting in the records, said Karen Kostick, a coding practice manager with the American Health Information Management Assn.

"Physicians tend to do a lot more in office visits, but it just doesn't get documented," said Kostick.

However, there are Web resources available to physicians that can help them brush up on the type of documentation they need to include in their patients' medical records.

Kostick recommended that physicians who want to review Medicare and Medicaid documentation guidelines go to the Centers for Medicare & Medicaid Services' Web site to access the centers' 1997 E&M documentation guidelines. [...]