Medical Billers Guide to the Patient’s Medical Record

If you are starting your career in the medical billing and coding, here’s a valuable information on learning the basics of your career that includes mastering the patient’s medical record.

The medical billing and coding process is all about submitting medical insurance claims to insurance companies for services rendered to their policy holders.

The process starts by looking at the patient’s medical record once the health care service is performed. Here’s a quick guide on what to look for in the patient’s medical record if you are a medical biller or thinking about becoming one.

The patient’s record will contain highly personal information; it will include nature of illness, examination details, medication lists, diagnoses, and suggested treatment.

These information will be necessary when you are determining the basis of the insurance claim. As a medical biller and coder, you will be required to convert all service items into its proper code as described in the CTS and the ICD-9-CM.

Personal information is also a must and should be present in the patient’s medical record. Details of the personal information are critical when submitting the insurance claim because an error in the personal information can lead to the rejection of the insurance claim.

Here are the critical personal information required from the medical record and critical to the insurance claim.

1. The patient’s complete name
2. Patient’s address
3. Social security number
4. Home telephone number
5. Work telephone number
6. Insurance policy identity number
7. If the patient is a minor, the guarantor information or a parent of adult related to the patient

These are the important personal information that you must get from the patient’s medical record which are critical in submitting the insurance claim.