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.

Cloned notes. Copied text that is not updated for the visit is not documentation of that visit.

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