BC Advantage - 2023 Issue 6

If a Procedure Was Not Documented, Was It Performed?

Most of us, if not all of us, have heard the statement, "If it isn't documented, then it wasn't performed." While I know this is often the perspective of payers, I cringe when I hear this, thinking about all the providers that I work with and the fact that it may not be a true statement that the procedure was not done.I recently had a conversation about this with a good friend who is also in the medical coding industry. She was working through a scenario where a surgeon was documenting only the name of the procedure...

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