DOCUMENTATION AND CODING INSTRUCTION

The documentation of the medical chart, whether on paper or EHR is essential to the proper coding (CPT and ICD-10) of the visit, procedure or surgery. Only the physician or therapist who has rendered the care can fully document and code the event.

Proper medical coding & documentation is essential to protect medical practices from audits seeking to recover funds for over billing. In the cases of Medicare and Medicaid the lack of documentation for a billed code can be considered fraud. The answer is not to bill lower codes than appropriate to “stay under the radar”, but to document and code correctly for the medical care provided.

We have AAPC certified coders who will instruct you in the privacy of your own office, how to document and code properly for the care given.