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[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed. [1] This bill is called a claim. [2]
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
For example, if a clinical coder or Health Information Manager was extracting data from a medical record in which the principal diagnoses was unclear due to illegible handwriting, the health professional would have to contact the physician responsible for documenting the diagnoses in order to correctly assign the code.
Medical billing is notoriously byzantine and rife with errors. Anytime you receive a bill, ask the hospital or healthcare provider for an itemized bill that includes the billing codes of all the ...
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Since 2006, the Justice Department has sued more than a dozen hospice companies for going too far in the pursuit of patients. The roster of companies accused of billing fraud includes Miami-based Vitas, the largest hospice provider in the nation.
Products such as Problem (IT) and Procedure (IT) aim to help physicians more easily choose the correct medical term for their cases, which then aids in finding the correct billing code. [1] This allows the clinician to capture the patient condition more accurately, with more familiar terms and without slowing the EHR workflow.