What is the implication for a procedure that is not documented during a review?

When a procedure is not documented during a review, the implication that it is considered to never have been performed is rooted in the principles of medical documentation and coding practices. Documentation serves as the evidence that a service was provided. Without proper records, there is no way to substantiate that the procedure actually took place, making it as though it did not occur in the eyes of insurers, auditors, and healthcare regulations.

This lack of documentation can lead to significant issues for healthcare providers, including challenges in reimbursement, compliance risks, and potential ramifications during audits. For example, if a procedure is not recorded, it cannot be billed or reimbursed, as insurance companies rely on thorough documentation of services rendered to validate claims.

Thus, the absence of documentation implies that the procedure is virtually non-existent from a billing and compliance perspective, leading to the conclusion that it is assumed never to have been performed.