Medical Records Documentation and Billing Detail

Since medical records contain vital information such as patient’s conditions and treatments, allergies, medications, lab and diagnostic reports and personal demographics. All medical facilities need to ensure that HIPAA and compliance rules are followed by every staff member. Also these records need to be kept precise, since these records are a physician’s medical findings and observations about a patient and are used in the care and treatment of said patient. Furthermore, these records are the physician’s first line of defense against medical malpractice lawsuits.

Compliance plans also allow the facility to detect problems early, to avoid legal action, and to train and educate staff members on new and updated policy and procedure. In addition to coding and billing, compliance plans cover other areas of government regulation concerning medical practices. The 10 steps in the medical billing process can be related to compliance plans, medical records, or documentation standards. Steps 1-4- the visit; which are generally the duties of the front office staff, are directly related to medical records.

These steps include the preregistration of patient, establishing financial responsibility, and checking patients in and out. Steps 5-7– claims; which are reviewing the coding compliance, checking billing compliance and preparing and transmitting claims, are related to both compliance plans and documentations standards. In these steps the biller and coders must make sure that all official guidelines are satisfied before the claims are submitted to the payors. This means that the documentation must support both the diagnosis and visit level in the claim. Steps 8-10-post-claim; which consists of monitoring payer adjudication, generating patient statements and following up on patient payments and collections all relate to compliance.

This individual must be familiar with the practices agreement with each payer in order to bill the patient correctly. The individual must also know what can and cannot be said and done when attempting to collect outstanding debts.

ReferencesValerius, J., Bayes, N., Newby, C., & Seggern J. (2008). Medical insurance: An intergrated claims process approach (3rd ed.) Boston: McGraw-Hil,l.