This is because these particular steps are the information that is entered into the patient’s semi-permanent medical record. This information includes any billing information, information about the patient’s condition and treatment. Steps eight through nine in the medical billing process relate to documentation standards. In order for the various forms to be accepted by the patient’s insurance company, or other payees the documentation must be
Evaluating Compliance Strategies HCR/220 February 24, 2013 Angela Colbert Evaluating Compliance Strategies This essay will evaluate the medical billing and coding compliance strategies. There are many mistakes that are made during the medical billing and coding process that could possibly be minimized with the proper strategies. In this paper the following questions will be addressed: What is the importance of correctly linking procedures and diagnoses? What are the implications of incorrect medical coding? How are medical coding, physician, and payer fees related to the compliance process?
The inpatient coder ensures that the data entered is relevant, indicating the reason that the patient was admitted, which involves the kind of illness and a breakdown of the treatment that was given (Henderson.) The inpatient coder uses the current version of ICD-CM classification for the most appropriate DRG assignment for assigning codes to diagnoses and procedures. They have to be able to determine the correct diagnosis and secondary diagnosis, identifying and assigning co-morbidities and complications and principle procedure codes. The inpatient coder is also responsible for selecting the proper DRG and Discharge Disposition Code. The impatient coder sends the documentation to HIM Operations for follow-up when Physicians documentation is not clear or straight forward.
(2013) Health LAW & Medical ETHICS for Healthcare Professionals. Upper Saddle River, New Jersey: Pearson. Freudenheim, Milt (2012).The Ups and Downs of Electronic Medical Records. Retrieved from http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html?pagewanted=all Hsieh, Paul (2014). Can you trust What's in Your Electronic Medical Record?
• Patient authority forms must be in written form to be valid • Must contain enough information to allow the patient to be identified correctly (e.g. date of birth, address) • Must indicate what information the health care facility is allowed to release and to whom it is to be released • Must be signed by the patient • Must be an original request (photocopies are not acceptable) • Must be current (authority should be less than three months old) Thankyou. Task 2 Using Word, you are required to write a report outlining the steps to follow when releasing confidential patient information to various sources. Instructions Commence your report with a short introduction on the importance of privacy and confidentiality of patient records. State your understanding of the important considerations when releasing information to the various groups who may request patient information from a health facility.
Healthcare decisions may have been made based on content before the correction was inserted. A computer audit trail associated with the EHR will provide, if required, information about when specific entries were made, what information was available at what time, who made the correction. 11. Give two examples of abbreviations on the Joint commission “Do Not Use” list and explain why each should not be used. • “U” or ”u” for unit can be mistaken for “0”, the # four or “cc” • “IU” can be mistaken for “IV” or the # 10 12.
It provides statistics on volume as well as financial costs of such errors. It investigates the possible contributing factors that lead to medical errors. The report attempts to simplify steps that can be done in order to reduce errors and improve quality in healthcare. It concludes by providing information on approaches all ready being considered in order to fulfill the goal or reducing medical errors. The Institute of Medicine functions under a congressional organization through the National Academy of Sciences.
Jessica knows somebody that had a cystectomy and is getting this procedure confused with a cystoscopy. Ectomy is a suffix, which means surgical removal, excision, and resection. Why would it be important for a Biller and Coder to know the difference between the two suffixes? Not only is it important for a Biller and Coder to know the differences between suffixes so the clinic is able to get reimbursed properly for services and avoid legal issues, but there are also ethical standards that have been put into place by the American Medical Association. If you fail to comply with proper documenting practices you could cause inappropriate payment increases or false insurance coverage or be skewing information to not comply with state or federal statutes and guidelines.
Nursing Documentation and Malpractice Law HCS/545 Health Law and Ethics May 31, 2010 Mary Nell Cummings Nursing Documentation and Malpractice Lawsuits Proper medical documentation can prevent liability issues and malpractice lawsuits. The focus on my paper will concentrate on nursing documentation and malpractice lawsuits. I presently work for a home health care agency. The entire staff throughout the company was recently informed of increased Medicare denials and possible lawsuits as results of inadequate documentations. A series of education training of documentation was implemented to help reduce episodes of Medicare payment denials and self-protection through adequate documentation.