Review the physician record (Notes presenting signs and symptoms, lab values, medical history and reason why the patient is or was being admitted.
Look for the physician's document of the patient's history and physical also known as H&P. (Ensure that there is enough clinical information in the chart to support the diagnoses the physician chose.)
Look at vital signs and intake and output. (This information can give you an idea of how sick your patient is.)
Review labs and radiology reports (Review reports for abnormal findings, consider clinical significance findings for the patient care)
Review procedures that may have been performed on the patient
Review all notes and dictations in-patient chart
Review documentation from other disciplines (we will look for nursing documentation and or dietary documentation …show more content…
Explain them in your own words.
The steps in medical billing are:
Patient Check -in- This is the first stage of the patients appointment and should include patient demographic information as well such as (insurance, policy #)
Insurance eligibility and verification- Insurance information can change at any time, so it is important to ask patient for insurance information before visit with the doctor
Coding of Diagnosis Procedures and Modifiers -The correct coding of is very vital for informing the insurance payer. Use accurate CPT and HCPCS code modifiers to provide additional information about the service and or procedure
Look for the physician's document of the patient's history and physical also known as H&P. (Ensure that there is enough clinical information in the chart to support the diagnoses the physician chose.)
Look at vital signs and intake and output. (This information can give you an idea of how sick your patient is.)
Review labs and radiology reports (Review reports for abnormal findings, consider clinical significance findings for the patient care)
Review procedures that may have been performed on the patient
Review all notes and dictations in-patient chart
Review documentation from other disciplines (we will look for nursing documentation and or dietary documentation …show more content…
Explain them in your own words.
The steps in medical billing are:
Patient Check -in- This is the first stage of the patients appointment and should include patient demographic information as well such as (insurance, policy #)
Insurance eligibility and verification- Insurance information can change at any time, so it is important to ask patient for insurance information before visit with the doctor
Coding of Diagnosis Procedures and Modifiers -The correct coding of is very vital for informing the insurance payer. Use accurate CPT and HCPCS code modifiers to provide additional information about the service and or procedure