Medical Records Documentation and Billing
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- Date Submitted: 12/02/2010 01:53 PM
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Medical Records Documentation and Billing
There are a few different ways that compliance plans correlate to medical records documentation. All of the staff should follow the rules for the billing process. Compliance plans are included in anything that satisfies the official requirements. Compliance is following guidelines and coding when codes are assigned. The documentation of a compliance plan consists of auditing areas of the coding and billing of medical records. Also in providing training for all staff who are continuing their education and consistently acquiring guidelines and procedures and if any errors have occurred make sure to take action to correct them.
Compliance plans correlate with medical records through correct documenting and guidelines of collecting information for the medical examinations. The medical records are very important documents for the physicians and patients, and without them the physician would have nothing to go by for their past medical problems or medications they have taken and it would be hard to get the proper diagnosis without them. This is why it is so important to make sure when you start seeing a new physician to make sure that they get all of your previous records from your former physicians. Medical records have to have compliance in billing as well; the records must provide correlating information that matches the codes of charges for services that have been rendered. All of the steps in the billing process would fall under correlation.
The compliance plan also correlates with the documentation standards because everything that is done must be documented for legal and medical purposes and all the information must be true and correct. If there is any false information on the physician’s part and even the patient’s part, legal action could occur.
There are a few different ways that compliance plans correlate to medical records documentation. All of the staff should follow the rules for the billing process. Compliance plans are included in anything that satisfies the official requirements. Compliance is following guidelines and coding when codes are assigned. The documentation of a compliance plan consists of auditing areas of the coding and billing of medical records. Also in providing training for all staff who are continuing their education and consistently acquiring guidelines and procedures and if any errors have occurred make sure to take action to correct them.
Compliance plans correlate with medical records through correct documenting and guidelines of collecting information for the medical examinations. The medical records are very important documents for the physicians and patients, and without them the physician would have nothing to go by for their past medical problems or medications they have taken and it would be hard to get the proper diagnosis without them. This is why it is so important to make sure when you start seeing a new physician to make sure that they get all of your previous records from your former physicians. Medical records have to have compliance in billing as well; the records must provide correlating information that matches the codes of charges for services that have been rendered. All of the steps in the billing process would fall under correlation.
The compliance plan also correlates with the documentation standards because everything that is done must be documented for legal and medical purposes and all the information must be true and correct. If there is any false information on the physician’s part and even the patient’s part, legal action could occur.