Medical Billers Guide To The Patient Record

A medical record is the most important file in health care. It includes the patient history, diagnosis, prior and current treatment and personal identification of a patient. It is very important not only in the clinical side of health care but also in the administrative side where the medical record is used as basis for billing of services rendered.

On the administrative side of health care, the medical record is used as the reason for the health insurance claim after the services contained in the medical record is processed and converted to standard and generally accepted medical codes.

Depending on the conciseness of the medical record, the health insurance claim produced through the information derived from it will either be approved and settled or rejected by the health insurance company. It is very important therefore that the medical biller must have a clear idea of the accuracy of the medical record and how to use it in submitting claims.

The medical record must be accurate and the personal information contained in it must be true. It must also contain the summary of services rendered to patients, along with the diagnosis and treatment provided. The patient’s personal information is the most important part of the medical record. Without verifying the accuracy of the patient’s personal information in the medical record, it can cause a lot of rejected claims resulting to services rendered to patients without the physician getting paid for rendering the service.

Here are some of the most common information in the medical record that you as a medical biller must make sure is accurate.

  • Patient’s Name
  • Patient’s Present address
  • Social Security number
  • Home telephone number
  • Work telephone number
  • Insurance Policy ID number
  • Guarantor information of the parent or adult for minor patients

The personal information above should always be checked for accuracy if you are a medical biller. This way proper billing, claims and settlement will be made after medical services are rendered.