What must always be included in documentation to support coded procedures?

The documentation supporting coded procedures must always include a description of the service provided and the medical necessity for it. This is crucial because coding relies on accurate and detailed records to reflect what services were rendered during a patient encounter. The description of the service outlines the specific procedure performed, while the medical necessity establishes the reasons behind why the procedure was required, ensuring that it aligns with insurance policies and reimbursement guidelines.

Inclusion of medical necessity supports the rationale for treatment, justifying that it was appropriate given the patient’s condition. This level of detail is essential for compliance with coding standards and for preventing potential audits or disputes with payers regarding reimbursement. Combined, these elements ensure that coded procedures are accurate and substantiated, which is vital for the integrity of medical billing and coding practices.