If a procedure is NOT documented in the medical record, it cannot be reported or billed.

Name: If a procedure is NOT documented in the medical record, it cannot be reported or billed.
Brand: Quizplus
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Question

Quizplus · Accepted Answer

This is because documentation serves as proof that the procedure was performed and necessary for patient care, and is required for billing and reimbursement purposes. Without documentation, there is no way to verify that the procedure was actually done, and therefore it cannot be reported or billed.

If a Procedure Is NOT Documented in the Medical Record