Why Quality Documentation Matters

Ambulatory Care Management
Saint Joseph Health System/Select Health Network
Mishawaka, IN

Clinical documentation refers to the recording of pertinent facts, findings, and observations related to an individual’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. It plays a critical role in helping physicians and other medical professionals plan treatments, monitor a patient’s health status over time, and ensure continuity of care. It also facilitates accurate and timely claims review and payment, appropriate utilization review and quality-of-care evaluations, and collection of data that may be useful in research and education.1 As discussed in this article, quality documentation is essential for ensuring the well-being of your patients as well as your practice.

What Is Quality Documentation and Why Does It Matter?

Clinical documentation should be complete, accurate, legible, and timely. According to the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual, every service should be documented while it is being provided—or as soon as possible after it is provided—to maintain an accurate record.2 The medical record should include the reason for the visit (including the patient’s progress as well as his or her response to or changes in treatment), health risk factors, and any significant personal, family, and social histories. It is important to reference any applicable previous diagnostic tests and lab results, to document the physical examination findings and plan of care, and to record the diagnosis or clinical impression. The medical record should also include the date of the encounter and the provider’s signature.2,3 Medicare requires that medical record entries for services provided, ordered, or certified be authenticated by the persons responsible for the care of the beneficiary. It is important for individuals to use a handwritten or an electronic signature. Stamp signatures are not acceptable.3

Documentation must support the medical necessity of the service and the diagnosis and procedure codes submitted for payment. It should also reflect the patient’s adherence to the established care plan and compliance to recommended clinical quality measures. This is critical for ensuring appropriate payment and reducing the denial of claims.

Avoiding Improper Payments

According to the 2020 Medicare Fee-For-Service Supplemental Improper Payment Data report, the majority of Part B improper payments were due to missing or inadequate documentation.4

The top causes identified for inadequate documentation include4:

  • Missing documentation to support medical necessity
  • Inadequate documentation to support the services were provided, or other documentation required for payment of the code
  • Missing provider’s intent to order (for certain services)
  • Missing order
  • Missing documentation to support the services were provided, or other documentation required for payment of the code
  • Inadequate documentation to support medical necessity

Staying Compliant

We have all heard the phrase, “If it’s not documented, it didn’t happen.” Maintaining accurate records supports the integrity of the claim submitted for reimbursement by ensuring that all services have adequate documentation to support their medical necessity. The False Claims Act imposes liability on any individual who submits a claim to the federal government that he or she knows (or should know) is false.5 The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment.

According to CMS, when a claim is submitted for services provided to a Medicare beneficiary, a bill is filed with the federal government certifying that the payment requested was earned and complied with the billing requirements.5 If an individual knows or should have known the submitted claim was false, then the attempt to collect payment is illegal. Examples of false claims include services not rendered, upcoding, services not supported in the medical record, and services that are not medically necessary.

Copying and pasting and overdocumentation can also pose potential compliance issues for the provider. Copying and pasting, also known as cloning, allows clinicians to replicate information. However, the information often is not updated, causing inaccurate information that can lead to inappropriate billing. Overdocumentation uses information irrelevant to the current encounter and has the potential to inflate the level of service. If a correction to the medical record needs to be made, the provider should clearly label the note as an addendum, correction, or late entry.

Record Requests and Audits

It is important to respond to a payer’s request for records in a timely manner. Pay close attention to the deadline and if you need an extension, request it early. Do not wait until the deadline date. Make sure the records are legible and legibly copied. Submit records for each date of service requested, including any radiology reports, lab results, and all other documentation associated with the claim. If you do not have records for a certain date of service, do not attempt to recreate the note. It is important to keep copies of all correspondence.


Quality documentation offers proof of services rendered and supports the medical necessity of those services, which is essential for receiving payment and avoiding denial of claims. It also facilitates coordination of care by allowing clinical information to be accessed by all healthcare professionals involved in the patient’s care, which promotes better outcomes. So, remember to document what you do and do what you document to protect you and your patients.


  1. CGS Medicare. Documentation guidelines for Evaluation & Management (E/M) services: reminders and updates. December 23, 2020. https://cgsmedicare.com/partb/pubs/news/2020/12/cope20068.html. Accessed September 5, 2021.
  2. Centers for Medicare & Medicaid Services. Medicare claims processing manual. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912. Accessed September 4, 2021.
  3. Novitas Solutions. Medical review signature requirements. Updated June 29, 2021. www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00004950. Accessed September 5, 2021.
  4. Centers for Medicare & Medicaid Services. Medicare fee-for-service 2016 improper payments report. July 27, 2017. www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2016ImproperPaymentsReport.pdf. Accessed September 6, 2021.
  5. Centers for Medicare & Medicaid Services. False Claims Act description. https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd032207att2.pdf. Accessed September 6, 2021.
Article provided through a partnership with
Practice Management Institute
Michigan Society of Hematology & Oncology

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