Medical Documentation

Medical documentation should provide detailed information, including the following:

  • Reason for visit
  • Body part or area where treatment is provided (e.g. thoracic)
  • Capabilities
  • Progress/ Improvement
  • Time (if applicable)

Documentation Policies

WSI’s Documentation Policies outline specific documentation components reviewed during the bill audit process:

Evaluation and Management

Falsified Medical Records

Physical Medicine and Rehabilitation Time-Based Services