How toDouble-Check Your Documentation in Medical Billing - dummies

How toDouble-Check Your Documentation in Medical Billing

Just as carpenters “measure twice, cut once,” before you send out a claim in medical billing, you need to check and double check your documentation to increase your chances for success (read, getting the requested reimbursement) the first time around.

Submitting a claim correctly with all necessary information required for prompt processing is known as filing a “clean” claim. A clean claim is one that can be processed without the payer needing to request additional information from the provider or a third party.

When you review each record during your final check for accuracy, remember to do the following:

  • Make sure that the patient name, address, date of birth, identification number, and group number are correct and populate the correct fields.

  • Check to see that all billable codes are documented.

  • Verify that the form contains no expired or deleted codes and that the codes have been entered correctly (no transposed digits).

  • Verify that medical necessity has been met.

    You must make sure that the documentation is relative to the diagnosis. The record should always include the reason for the patient encounter. In addition, any and all procedural codes submitted for payment must be supported by the appropriate diagnosis code that supports medical necessity.

    When a diagnosis is entered into the record, a decision regarding treatment usually follows it, if it wasn’t actually treated at that time. Diagnosis codes such as these that are part of the medical record but that seem to just “be there” may also be subject to physician query. If a billable procedure is obviously missing, indicate that to the physician. Ask her to clarify the record.

  • Make sure the record is complete and that all fields are populated.

  • Check that all required signatures are dated, especially physician signatures. Electronic signatures also show a time and date stamp.

  • If the physician completed a super-bill (a billing form used in many providers offices that includes the most frequently performed procedures), verify that the procedures indicated on the bill are documented in the record.

  • Verify the prioritization of the codes in relation to the payer-specific contract. Know which codes are obligated for higher reimbursement. (The payer may want the highest paying code listed first on the claim.)

  • Check for bundling/unbundling issues.

  • Make sure that the payer is correctly identified, including the right payer identification number and payer mailing address.

After you make sure that all of these elements are in place, submit that puppy! The preferred method of submitting claims is electronically. Electronic submission is faster, and allows the provider to verify that the payer accepted the claim. The clearinghouse will acknowledge the receipt of each claim and will also generate an acceptance report if one is returned by the payer after the assigned payer has accepted the claim.