Proper documentation is critical to justifying medical necessity and selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone. For example, auditors interested in services provided on Aug. 18, 2012 will only review that note; they will not look at notes from other visits unless referenced in the note from Aug. 18, 2012.
To assist cardiologists interested in improving documentation, the ACC has developed resources on the topics below. Questions are welcomed and should be directed to firstname.lastname@example.org.