Question

What types of information do you think would need to be included in all documentation of services provided to adequately support coding and billing, and, therefore, reimbursement? (i.e. list document principles/elements). Discuss the issues that may arise when "copy and paste" methods are used.

Answer 1

Principles of Documentation that needs to be followed are

Concise and concrete data:- it means all the details of services provided to the patient during the course of his/her stay in hospital should be in neat legible writing so that the service providers exactly understand.

Mention date and time always as it remains as a record for service provided/ care given.

Documents are to be kept in safe place.

Confidentiality to be maintained at all point of time. Documents are not to be disclosed to the third person without prior permission of hospital authority.

While coding ensure that it is done in a proper manner and is universally understood by the Health care provider.

Billing documents are to be arranged sequentially in order of the services provided to avoid misplacing/lost/stolen.

Most of the times services provided are similar except for few things in medical department.Hence billing personnel should always check all the documents in respect of patients name , stay in hospital and method of payment.

Generally patients are covered by health insurance and reimbursement is done later on by the TPA i.e third party administrator which can be any health insurance company and the patient does not have to pay for the services rendered.

Service provider should check whether the TPA is empanelled with the hospital or not.

Copy and paste methods are not acceptable.

Services rendered to every patient differs in all respect. It may cause loss / profit to both patient and service provider.

Also the issue comes when there is medical audit and such documents appears. It can have adverse impact on the image of the Hospital/service provider. It can lead to sue of licenses of practitioner, and the liability of fraud with patient.