Importance of Provider Documentation in ASC Revenue Cycle Management

Compliant and optimum ASC coding and billing are dependent on the provider supplying complete and accurate documentation. The following guidelines for medical record documentation apply to all types of medical and surgical services in all settings:

• Documentation should be legible and complete.
• Documentation should state the reason for the encounter (encounter includes surgical/procedural services), history, physical exam, diagnostic/therapeutic results, assessment, treatment plan, date and provider.
• If not documented, the reason for diagnostic tests or other services should be easily observed.
• Past and present diagnosis should be documented along with any risk factors.
• Response to and changes in treatment or diagnosis should be clearly documented.
• Critical: Services billed should be supported by the medical record documentation in any setting.

According to the old Medicare adage, "If it's not documented, it didn't happen!"

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