Medical Records Documentation and Billing
Devina Caruthers
HCR/220
October 8th, 2010
Medical Records Documentation and Billing
Compliance plans play a huge role in documenting medical records and billing. A compliance plan is preventing fraud from occurring in medical offices and finding and fixing errors in medical documentation and billing. The documentation also follows the rules of the compliance plan as well.
When it comes to billing and compliance plan the steps in the billing process have to be done right by the rules and regulations of the compliance plan. The medical records have to have the right coding for the billing to be correct as well. The wrong letter or number in a code can cost overcharging or undercharging. The overcharging can cause a fraud to medical practice even though it was a honest mistake. Some may not be honest mistakes but still the provider of the facility has to pay the price. Therefore, the provider has to make sure his or her staff has the correct training and when new training needs to be implemented for the staff of the facility. Documentation standards are taken serious due to the issue of identity fraud if the rules and regulations is not followed it can be costly to the provider as well.
There are different forms of documentation just depends on what the information is at the time. Therefore, the steps of documentation, billing needs to be done in timely fashion but done correctly though to keep from affect the compliance plan. The rules and regulations need to be followed at all times to keep patient information safe and mistakes from happening and causing a costly problem to medical faciltiy.