The medical practice today relies on medical claims to be correctly coded and billed. Improper medical claims filed result in loss of revenue to a medical facility, fraud investigations, financial sanction, disciplinary action, and exclusion from participation in government programs (Adams, Norman, & Burroughs, 2002). The encounter with a patient involves a series of actions. First the physician sees the patient and then signs documentation of the visit. Codes are assigned based on the documentation provided by the physician. The encounter is then billed from the codes assigned according to the documentation. The procedures performed must be linked directly to the services that are being billed. Medical record documentation is evidence of coding and justification for billing. Failure of the physician to appropriately document the medical records could result in improper coding and erroneous billing. If the procedure and diagnosis are not supported from the documentation then there is a risk of the claim being denied which could result in delays in receiving payments, reduced payments, fines, and ultimately the loss of the physicians license to practice medicine (Adams et al., 2002). The documentation provided in the medical record is viewed as the basis for coding and billing determinations. To assure that the appropriate medical documentation is accurate the following steps are used (Adams et al., 2002). 1. Practice timely, accurate and complete documentation.
2. Use appropriate diagnosis codes for examination and personal history. 3. Link appropriate diagnosis with appropriate procedure code. 4. Use modifiers appropriately.
5. Identify other insurance coverage when billing Medicare.
Adams et al. (2002) states that the Office of Inspector General (OIG) recommends the following minimum compliance for medical record documentation: * The medical record should be...