is not documented to validate the diagnosis, the diagnosis will be rejected by CMS due to the lack of evidence by provider. For medico-legal purposes, complete documentation provides evidence of a diagnosis, that is, “if it was not documented, it does not exist”.įor success with documentation, clinicians should make sure it adheres to M.E.A.T. These four factors help providers to establish the presence of a diagnosis during an encounter and ensure proper documentation.
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