Lesson · Lesson 4 of 5
Documentation that supports the claim
- MI-07Judge whether documentation supports the services billed
- MI-13Recognise indicators of fraud, waste and abuse in claims and documentation, and state the record-based response
The record decides what may be billed
A claim is a set of assertions about what happened. The record is the evidence for those assertions. When the two disagree, the record wins — not because it is more accurate, but because it is what a reviewer will read.
The working question is narrow and answerable: *for each line on this claim, is there something in the record that would satisfy someone who did not perform the service?* Not "did it probably happen", and not "is it usually done". Something written down.
A billed service is supported when the record independently shows it was performed and why. A note that describes an intention, an order, or a plan is not evidence that the service happened.
Whether the service was appropriate for the documented condition. A service can be genuinely performed, correctly coded, and still unpayable because the record does not show why it was needed.
Training example: imaging is documented as performed, but nothing in the record explains what question it was meant to answer.
| What the record says | What is billed | Supported? |
|---|---|---|
| "Extended assessment performed; findings recorded." | Extended assessment | Yes — the service and its performance are both stated. |
| "Imaging to be arranged." | Imaging | No — an intention, not evidence that it happened. |
| "Two short follow-ups arranged over the next month." | Two follow-ups | Only once they occur; arranging is not delivering. |
| "Patient reviewed." | Extended assessment | No — the record does not support the level billed. |
This pressure is usually not dramatic. It arrives as a suggestion that a code "probably" applies, or that a service is "always" done at this level. The defence is the same either way: point at the record. If the record does not say it, the claim should not either, and the person asking is better off knowing that before submission than after an audit.
| Signal | A single error | A pattern |
|---|---|---|
| What you see | One claim does not match its record. | The same mismatch recurs across many claims, often for one clinician or one service. |
| What it usually is | A slip: a wrong field, a missed or duplicated line. | A practice: something is being done the same way, repeatedly. |
| Which way the money moves | Either way, with no consistent direction. | Usually towards higher payment. |
| The record-based response | Correct the claim to match the record, then resubmit. | Escalate through the compliance route, citing the claims and what each record shows. |
| What not to do | Change the record so it fits the claim. | Quietly fix each claim yourself, so the pattern is never examined. |
Key takeaways
- For every line, ask whether the record would satisfy someone who did not perform the service.
- An intention, an order or a plan is not evidence that a service happened.
- A service can be real, correctly coded, and still unpayable if necessity is not documented.
- Upcoding and unbundling often pass automated checks, which is why they are integrity matters rather than errors.
Reading a record the way a reviewer does
A claim bills an extended assessment and one follow-up visit. The record reads: "Extended assessment performed; findings recorded. Follow-up arranged for next month."
Reviewing a month of claims, you notice that one clinician's visits are billed at the highest assessment level far more often than colleagues' visits, and the notes behind them are brief and very similar to one another.
Knowledge check — not scored
Which of these notes supports billing a follow-up visit?
Select one answer.
Knowledge check — not scored
Two sets of claims both contain mismatches with their records. In the first, the mismatches raise the amount on some claims and lower it on others. In the second, every mismatch raises the amount. Which should be treated as a pattern to escalate?
Select one answer.