Medical Records and Documentation Billing
Dawn Ott
January 23, 2014
Jessica Ellis

Medical Records and Documentation Billing

Compliance plans were put into place in order to make sure that billing riles are being followed by each and every staff member this includes any one that works with a patient medical record, front office staff, billers and coders. The compliance plans were also put into place to ensure that all patients’ records are kept accurate with any and all conditions, diagnoses, and treatment the patient has received at any time. In the event of a lawsuit, the patient’s records are the physician’s best line of defense.
When it comes to compliance plans, steps five and six in the medical process are the ones that would be related. It is the billing and coding employee’s responsibility to make sure that they use the correct coding when diagnosing and listing a procedure. You must comply with these official coding guidelines to determine the medical necessity of the charges.
With regards to the medical records, steps one through four are related. It is a requirement of the office staff to make sure that they are following the correct procedures when obtaining the required personal and insurance information. They are also required to make sure that all HIPAA guidelines are followed when giving out patient information.
The documentation standards fall under steps four through six. Any and all medical procedures need to be documented on the patients’ medical record; this is the only way that it can be billed to the patient’s insurance. This can include anything from office visits, lab tests, x- rays, any surgeries (Valerius, Bayes, Newby, Blochowiak, 2014).

Valerius, J., Bayes, N., Newby, C., Blochowiak, A. (2014). Medical insurance: An integrated claims process approach (6th ed.). Boston, MA: McGraw- Hill.

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