Medical Records Documentation and Billing
Compliance plans correlate to different medical records documentation standards in a few ways. First there are steps that are included in the process. Compliance plans are included in anything that satisfies official requirements. Compliance is included in coding and following guidelines when codes are assigned. Everything that is coded has to be double checked for errors. Making sure that everything is correct is part of compliance. All of these things are considered in steps 5 and 6. Compliance plans correlate with medical records through correct documenting and guidelines of collecting information for medical examinations. Medical records are important documents for physicians and patients. They hold the information that is needed in remembering proper diagnosis and resolution of situations. Medical records have to have compliance in billing as well; the records must provide correlating information that matches the codes of charges for the services rendered. I would say that all steps in the billing process would lie under this correlation. It’s important to get medical records complete and correct. Compliance plans correlate with documentation standards because everything must be documented for legal and medical purposes. All information must be true and correct. There is not room for error when it comes to documenting in medical situations. Legal repercussions can and will occur if there is any false information on the physicians end or the patients end. It is very important to get everything completely correct when it comes to compliance and documentation. Any step that has patient information or documenting of any kind in it would be included in this correlation.
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