Compliance & RegulatoryQuestion 94 of 100
Accurate and complete medical record documentation is important for billing because:
a.It sets the provider's tax rate
b.It replaces the need for coding
c.It supports the codes billed and demonstrates the medical necessity of services
d.It determines the patient's premium
Explanation
Documentation in the medical record must support every code reported and justify that services were medically necessary; the principle is that if it was not documented, it was not done. Insufficient documentation is a leading cause of denials and audit findings. Coders should assign codes based only on what the record supports.
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