- Medical Records is a document that includes patient information, provider information, and treatment information.
- It helps coders to code CPT, Modifier, and Diagnosis Code.
- It includes below information,
1. Patient Name
2. Patient DOB
3. Referring Doctor
4. Rendering Doctor
5. Service Location Information
6. Exam time
7. CPT code with description
8. Indication: It indicates the sign and symptoms of the patient current illness/disease.
9. Technique: It gives a brief description of the procedure which is helpful to code the CPT.
10. Findings: These represent the abnormal things found during the treatment.
11. Impression: It represents the conclusion of the treatment. Based on this information, the Diagnosis code can be coded.
- Indication, Technique, Findings & Impression fields are useful for the Coder to code the CPT, Modifier, and Diagnosis Code.
- From an AR perspective, when the same service is billed twice and one of them is denied for duplicate, you can check the rendering doctor & exam time to conclude the duplicate service.
- When a claim is denied for coding-related issues then the AR team is recommended to assign the claim to the coding team to check & code it correctly.