What is Medical Records?

• 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.