While the statement “Not documented, not done” is common in the healthcare compliance and coding community, there is a legitimate question as to whether this statement is supported by an actual rule or is nothing more than an urban myth that is repeated with such frequency that it has, based on nothing more than common perception, become a “rule.” There is no doubt that the documentation of services has become a de facto requirement for reimbursement when services are reviewed by carrier benefit integrity units. Nonetheless, investigation into the true basis for reimbursement under the Medicare program as well as a review of the Medicare statute, regulations, and Department of Health and Human Services (HHS) audit guidance provides little basis for this commonly perceived “rule.”
