Medical Records Documentation and Billing Sample Essay

Conformity programs correlate to different medical records certification criterions by supplying guidelines for what should be included in a patient’s file. For illustration. a six month old babe is seen in the physician’s office. This kid should hold an immunisation record in his medical record. The parent may decline the immunisations for the kid but it should be noted in the record that the immunisations were due and the parent refused them. Another illustration of how conformity plans correlate to medical records is when a 45 twelvemonth old adult female is seen by her doctor and is at the age that a mammogram should be performed. This patient should hold a record of anterior mammograms in her medical record and be offered the showing every one to two old ages. Non-compliance with the program would intend that the doctor did non offer this service to the patient or if the service was offered. the doctor failed to tag it in the file. Conformity programs are related to stairss five and six of the medical charge procedure.

Those stairss are reexamining coding conformities and look into charge conformities. Step five ensures that the right codifications are assigned for any process and diagnosing and that the diagnosing follows a logical order so that it can be understood by insurance company. Step six ensures that the patient’s visit is billed right and that merely the billable codifications are charged for. Medical records are covered by stairss one through measure 4 of the medical charge procedure. In these four stairss. the medical records are created. the patient’s personal and insurance information is collected and the patient cheques in and out of the office. Document criterions are covered in all 10 stairss of the medical charge procedure. The procedure begins with the creative activity of the patient’s medical record. continues through the visit with the doctor where he or she adds notes to the record. and ends with the charge and aggregation of money for services rendered.