Saturday, 14 December 2013

Medical Billing Errors: What can go wrong? What can you do? - 5 - Compiling the bill

Medical Billing Errors: What can go wrong? What can you do? - 4 - The inpatient stay

Step 4: Compiling the bill

About a dozen people work in the first stage of actually compiling the document that becomes the bill. Hospital staff collect the medical chart, often paper, to scan and merge it with the existing electronic record. The result is an electronic medical record with hundreds -- perhaps thousands -- of entries for people to assign codes for billing purposes. All of the text is summarized in codes -- the universal language of medical billing.
Chart collection

While hospitals are moving toward all-electronic medical records, few are there yet. Most of them have both an electronic medical record and old-fashioned paper charts that must be merged electronically.
• At many hospitals, such as Summa Health System's Akron City Hospital, one of the first steps in the coding process begins with a hospital administrative clerk who collects the paper chart after a patient has been released, and takes it to a scanning room.
• There, another clerk reviews the document to make sure all the pages are there and the chart appears complete and ready to scan.
• This person scans the paper document and marries it with the electronic medical record. A quality-assurance person, who is part of the hospital's scanning operation, reviews the electronic medical record, to make sure the scanned pages show up and are legible.
A universal bill
The complete electronic medical record will serve as the official story of the patient's surgery and care. It's made available electronically to a group of people who work concurrently, adding codes to the text entries in the next step.
• A coder starts to review the chart to code the diagnosis, and an abstractor screens the chart to fill in missing interactions, dates and billing elements. A clinical documentation specialist reviews the entire electronic medical record for missing treatment entries and required billing elements.
• Often the documentation specialist will have to speak with a case-management person  or several members of the clinical staff to clarify entries or obtain missing information.
• Many hospitals have a physician adviser who can review charts with the documentation specialist if necessary.
 Many health systems have an additional specialist to review charts in the cases of illnesses that may be on a hospital's "focus list" or at high risk for a government audit. In these instances, the medical record is reviewed again to make sure it's complete and that clinical quality measures were met.

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