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Medical Coding and Billing Guidelines For Health Services - The Importance of Documentation
January 24, 2015


When coding and subsequently billing Medicare or a commercial carrier for services rendered to one of your patients, there are certain billing guidelines that must be followed by you, the provider. If these guidelines are not followed, the ramifications are staggering!! Since Medicare is the primary insurance company that we deal with, the billing guidelines that will be discussed primarily are in reference to Medicare. However, don’t be fooled. The private insurance carriers follow what Medicare does very closely.

Billing Guidelines:

1. The service (s) must be medically necessary. This is by Medicare’s definition, not yours.
2. The service (s) must be performed: If you bill for a service and did not perform the service, it is quite apparent that the service was not performed. However, if you bill for a service and performed a different service, that service that you billed for was not performed either.
3. The service (s) performed must be sufficiently documented to show medical necessity.

Number three above is the most important guideline for billing services rendered. This is everything. It all comes down to documentation. You can be a highly credentialed physician. You do great work. You are honest. You bill exactly what you perform. However, if you don’t document sufficiently for the services rendered, it is as if you did not perform the work at all.

When a physician is audited by a carrier, specifically Medicare, you are generally asked for specific dates of service, not the entire chart. If the date in question contains entries such as “same”, or “C&C”, or “O.K.” or some nomenclature that is not the standard, there is a problem. The documentation for the date in question should be able to stand on its own. If another physician picks up your chart and reads it, he or she should have no trouble understanding what the situation at hand is and what care was provided to the patient.

Well, Medicare has a specific stand on documentation:

  • If it is not documented, then it did not happen.
  • If it cannot be understood, then it did not happen.
  • If it cannot be read, then it did not happen.
  • If it did not happen, then it should not have been paid.
  • If it was paid, then they will ask for the money back.

When they ask for money back, it is never at face value. The always attach a very big “tip”.

Did you ever notice that they always pay you first, right or wrong?

Just because you get paid, doesn’t mean that you did everything correctly. All audits are post-payment with very few exceptions. The only thing that you possess that shows the carrier that you performed the work that you billed for is your documentation.

How do you measure up?

Michael G. Warshaw, also known as Dr Mike the Coder, is a practicing podiatrist and a certified medical coder and consultant with over 25 years of successful coding, management and training experience for podiatric practices. Through his web site, he offers medical coding and billing services, such as audits, compliance, consultation, education and forensic coding. His local and national views come from active participation as a practicing podiatrist, having the distinction of being a certified professional coder, and years of serving as a national lecturer concerning coding issues.