Documentation and notes
Documentation completeness and compliance checks
Run the administrative compliance checks: time match, documentation completeness, service authorization, and billing code validation, and fix what they flag before a claim leaves.
Two surfaces keep documentation honest before billing: Documentation > Completeness, and the Billing Compliance Dashboard.
Documentation completeness
Lists visits whose notes are missing something a claim needs: a signature, a diagnosis code, a procedure code, minutes on a timed code, or a linked plan of care. Each row opens the note.
The Billing Compliance Dashboard
Run Compliance Check evaluates recent visits against four check types:
- Time Match Verification compares the session duration with billed minutes.
- Documentation Completeness verifies required fields are present.
- Service Authorization confirms the service is within authorized limits (visits and units).
- Billing Code Validation checks code and modifier combinations.
Results are Passed, Warnings, or Failed with an overall compliance rate, a distribution chart, and the list of recent checks.
What to do with a failure
Open the visit from the check, fix the note or the booking (for example add the authorization number), and re-run. Claims for failed visits stay in Needs correction until the check passes.
Frequently asked questions
Are these clinical judgments?
No. They are administrative checks: is the field present, do the minutes match, is the service inside the authorization. Clinical judgment stays with you.