Medical Records Documentation & Billing

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The compliance plans correlate with medical records documentation standards in which all staff members should follow billing rules. The documentation of a compliance plan consists of auditing areas of the coding and billing (medical records), providing ongoing training for all staff (continuing education), acquiring guidelines and procedures consistent, and to take action to correct any errors that may have occurred. For example all coding, within the medical record, must meet official guidelines. Not all codes are billable, but for every procedure, or documentation the patient has there must be a code listed. The documentation standards is the listings of procedures within a medical record stating which part of the bill is paid by the insurance plan and the part of the bill stating the patient’s bill. The relationship between the compliance plan and the medical record documentation standard would be to have everything found, and corrected before the physician signs the billing statement. If not done completely and accurately, both the staff member entering this information and the physician could be negligent and charged with fraudulent behavior.

Within the medical billing process, compliance plans help prevent fraud and abuse from occurring and any repeat violations from happening. The medical records will also be accurate and complete and the documentation standards will be met by both the staff members and physicians within the compliance plan.

Keeping the staff members current with their training and up-to-date with the rules and regulations within a facility will keep the compliance plan for the medical records documentation standards enforce.
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