Medical Records Documentation and Billing

Compliance plans are put into place to find, correct, and prevent illegal medical office practices. In correlation with medical records documentation standards, these plans eliminate the possibility of errors by training staff members who work with medial records including front office staff along with billers and coders. Steps five and six of the medical billing process are related to compliance plans. In coding and billing, it is necessary to use correct diagnosis and procedure coding when assigning them to an encounter.

Complying with official coding guidelines is a must to determine medical necessity of the charges. Steps one through four are related with medical records. The front office staff is required to follow specific procedures in obtaining demographic and insurance information from the patient. Based on HIPAA guidelines, this information is not allowed to be given to anyone without written consent of the patient. Also, when checking out patients, the physician or medical coder needs to assign procedure and diagnosis codes following coding guidelines.

Steps four, five, and six in the medical billing process are also related to do documentation standards. All medical procedures must be documented in the patient’s medical record to bill their insurance. If it is not documented, it can not be billed. This includes, but is not limited to, using the correct diagnosis and procedure codes for billing, documentation of procedural services such as lab tests or surgeries, and evaluation and management reports (Valerius, Bayes, Newby, & Seggern, 2008).

ReferencesValerius, J., Baynes, N., Newby, C., & Seggern, J. (2008). Medical Insurance: An Integrated Claims Process Approach. Boston: McGraw-Hill.