What is the triad for billing and coding?

The triad for billing and coding is anchored in three crucial elements: what was performed, what was documented, and what was billed. This triad is essential for ensuring accurate and compliant billing practices in physical therapy and other healthcare fields.

Firstly, 'what was performed' refers to the actual services or interventions that were provided to the patient during their therapy sessions. This statement captures the tangible actions that the clinician took, such as specific exercises, modalities, or evaluations.

The second element, 'what was documented,' is critical as it ensures that all actions taken during therapy are officially recorded in the patient's medical records. Documentation serves as a legal record and provides evidence supporting the services billed. It should align with the performance of the treatment to reflect a complete and accurate representation of the patient's care.

Lastly, 'what was billed' encompasses the actual charges submitted to third-party payers or insurance companies for reimbursement. This requirement emphasizes that the services billed must correspond to both what was performed and what is documented in the patient's records.

Collectively, these three components help create a comprehensive narrative of patient care and are fundamental for compliance with billing regulations. They ensure that the healthcare provider is reimbursed appropriately for the services rendered while maintaining transparency and accountability in the healthcare system.