How important is proper documentation in the medical record to support a claim?

Buried in documentation?  Looking to save yourself time and trouble?  Rather than cutting corners and skipping paperwork, you’ll actually save time and significant risks if you commit to full and proper documentation in the medical record to support each submitted claim.  

If the records do not substantiate the service reported and show medical justification for the service, you may have claims rejected on a first review, or you may contend with a much larger problem of a later audit, with fines, penalties, recoupment of all amounts paid – and potentially allegations of fraud or abuse. Trying to document or justify after-the-fact never works out! Just say no! Accurate documentation, entered in the chart at the time of service, ensures your organization will receive proper compensation for services you provide, and provides a strong defense when you are audited.

The OIG promotes the practice of proper documentation to ensure patient safety, provider protection, and program integrity. So, make sure sufficient documentation is a priority in your organization!

Sources:

Importance of Documentation