Documentation Policies Available

February 2017

WSI recently implemented Documentation Policies to reinforce existing guidelines and/or clarify documentation standards. The following three new policies outline WSI’s expectations of specific documentation components reviewed during the bill audit process.

  • Evaluation and Management (E&M): This policy replaces the existing guidelines regarding WSI’s adoption of the 1997 Documentation Guidelines for Evaluation and Management Services from the Centers for Medicare & Medicaid Services (CMS) for the auditing of E&M services.
  • Falsified Medical Records: This is a new policy which outlines that WSI considers any record containing non-authentic documentation as a falsified medical record.
  • Physical Medicine and Rehabilitation (PM&R) Time-Based Services: This policy clarifies WSI’s adoption of the HCPCS coding requirements from The Centers for Medicare & Medicaid Services (CMS) for the evaluation of documentation and billing of time-based PM&R codes. 

A provider should review the new Documentation Policies in conjunction with WSI’s Fee Schedule Guidelines to ensure the submission of proper documentation and billing.

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