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Coding tip of the day: 'If you didn't document it, it wasn't performed'

Documentation is the most important part of coding and billing, according to Alliance Medibilling CEO Annette Bolcato. She said the majority of denied claims her company sees are a result of insufficient documentation.

Ms. Bolcato shared the following tip with Becker's ASC Review.

"There's a saying: 'If you didn't document it, it wasn't performed,' and that's very true. It has to be documented. I see it with most of our clients now. We can't stress enough how important it is, across the board. We're living in a world where everything you say has to be documented."

If you would like to share a coding & billing tip to be featured in our "tip of the day" series, please email Angie Stewart at

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