The Golden Rule: ‘Not documented, not done’  

Strong documentation is the key to effective coding. Without accurate clinical notes, compliance risks increase and reimbursements are reduced. ReveNews recently spoke with web2pro certified coders about common documentation errors in pathology.

Pathologists are costing themselves money each time they fail to include a key word or words in their pathology reports, according to Jerri Lea Key, SCC, CPC, director of pathology coding for web2pro Business Performance Services (web2pro).

“The golden rule in coding is `not documented, not done’,” Key said. “As coders, we’re only as good as the documentation that is provided to us.” 

Experience has shown that merely adding one key word can significantly reduce a practice’s variance/error rate, Key said. Pathologists should incorporate language and key words found in the CPT descriptors when dictating their final pathology report, she added. 

Physicians should keep in mind that auditors also follow the “not documented, not done” rule. And because most auditors are not specialty trained, they typically will reject any service provided – however routine it may be -- that isn’t clearly spelled out in the clinical notes. Doctors therefore can better withstand a coding audit and improve their changes of avoiding refunds to the payer if they use CPT common procedural language in all cases.

Common Mistakes

Here’s an example of what can happen when the correct language is omitted: Both the pathologist and coder know that the decalcification process was performed in connection with a bone marrow case. However, because the word "decal" was not included in the final pathology report, the coder is prevented from applying CPT code 88311 for the service. This, in turn, results in lost revenue.

Another area where seemingly insignificant omissions can lead to lost revenue involves breast specimens. If the pathologist states that he or she reviewed the surgical margins, the CPT code applied should be 88307. But failing to mention the margin review means the coder must apply the lower CPT code 88305. 

Similarly, physicians should always include the methodology utilized for cytological specimens. Not mentioning the fact that the specimen was performed using a liquid-based methodology would likely mean the coder would have to apply a lower valued CPT code.

Key said that when web2pro coders are asked to evaluate documentation and coding for potential clients, the most common error seen involves applying codes for services that were not documented in the physician’s report. Ironically, the second most frequent error is just the opposite: Not billing for services that were clearly documented.

ICD-10 Coming

“The pathology report is the roadmap coders must follow to code and file a claim,” Key said. “If that map is incomplete or inaccurate, it basically means the physician won’t get paid for all the services provided. It is therefore critical that pathologists invest the time to make their documentation as accurate, consistent and complete as possible.” 

She added: “The key to a healthy practice is to start with good, clear documentation. This leads to clean claims and hopefully, a quick turnaround with accurate reimbursement.”

And as important as accuracy is in today’s environment, detailed and precise clinical notes will become even more essential once the ICD-10 code sets take effect in October of this year, Key said. ICD-10 documentation requires considerably more clinical and anatomical specificity than the current ICD-9 system.


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.