What to Document Each Day as a Medical Coding and Billing Associate - dummies

What to Document Each Day as a Medical Coding and Billing Associate

As a medical coder and biller, a great way to keep all of your coding activities on the up-and-up is to spend some time each day writing down (or typing up) what you work on each day. You should keep a time log for each project, making special note of any claims that have trouble getting through the claims process.

Not only does such a record keep you up-to-date on deadlines and how things are going with your claims, but it also provides a history should anyone question why certain decisions were made. In your documentation, record any special circumstances that affect a claim, such as the following:

  • The date on which you must submit a corrected claim

  • When a patient calls to make special payment arrangements

  • Whether a claim was initially rejected and what action was taken

  • If a claim paid incorrectly, the date the payment was received and the reason it was incorrect

  • Any action taken as a result of incorrect claims processing, calls, letters, and so on

  • All circumstances concerning a medical record and the reason the services were necessary (medical necessity)

  • The patient’s consent to services and agreement to be responsible for payment

  • The date a payment was received and from whom

  • The date the claim was submitted to the secondary payer and any communication that resulted from that submission

With all claim documentation, make sure that you include the names of the people you spoke to, the date and time that the conversation took place (most software records this automatically), and all details of the conversation.