Medical Records Documentation and Billing

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Medical Records Documentation and Billing

Medical Records Documentation and Billing

Compliance plans correlate to different medical records documentation standards by providing guidelines for what should be included in a patient’s file. For example, a six month old baby is seen in the physician’s office. This child should have an immunization record in his medical record. The parent may refuse the immunizations for the child but it should be noted in the record that the immunizations were due and the parent refused them. Another example of how compliance plans correlate to medical records is when a 45 year old woman is seen by her physician and is at the age that a mammogram should be performed. This patient should have a record of prior mammograms in her medical record and be offered the screening every one to two years. Non-compliance with the plan would mean that the physician did not offer this service to the patient or if the service was offered, the physician failed to mark it in the file. Compliance plans are related to steps five and six of the medical billing process. Those steps are reviewing coding compliances and check billing compliances. Step five ensures that the correct codes are assigned for any procedure and diagnosis and that the diagnosis follows a logical order so that it can be understood by insurance company. Step six ensures that the patient’s visit is billed correctly and that only the billable codes are charged for. Medical records are covered by steps one through step 4 of the medical billing process. In these four steps, the medical records are created, the patient’s personal and insurance information is collected and the patient checks in and out of the office. Document standards are covered in all ten steps of the medical billing process. The process begins with the creation of the patient’s medical record, continues through the visit with the physician where he or she adds notes to the record, and ends with the billing and...
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