Coding and documentation integrity

Purpose. Every claim reflects the care that was documented. This is a written standard under the practice compliance program.

Documentation first. Coders code from the signed note. They never add a diagnosis or raise a level that the note does not support.

Queries. When documentation is unclear, coders send a query to the physician. Queries are neutral and never suggest the answer that pays more.

Audits. A sample of claims per physician is audited every quarter and the results shared with the physician.