Complete Story
06/15/2023
If a Procedure Was Not Documented, Was It Performed?
Most of us, if not all of us, have heard the statement, "If it isn't documented, then it wasn't performed." While I know this is often the perspective of payers, I cringe when I hear this, thinking about all the providers that I work with and the fact that it may not be a true statement that the procedure was not done.
I recently had a conversation about this with a good friend who is also in the medical coding industry. She was working through a scenario where a surgeon was documenting only the name of the procedure in the heading of an operative report and no details were listed in the body of the report. She was being questioned and pushed by leadership to code from the heading only (I can hear you all gasping now!) after they were made aware that no details were noted and were told this is against guidelines. I myself have seen this and it can be frustrating when the organization or provider is failing to see the large compliance risk that exists.
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