PubMed · 10883574
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W L Adams. 2000. Coding concepts.. https://pubmed.ncbi.nlm.nih.gov/10883574/
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The Netherlands have the 'Wet op de Geneeskundige Behandelingsovereenkomst', a law concerning the medical treatment agreement with the patient. Among other things it regulates the duties regarding the keeping and destruction of medical records. A critical evaluation is necessary, because the existing regulation is expected to have a negative effect on patient care and on scientific research. Development of better criteria for destruction of medical records is necessary. Until then, the destruction of medical records should be stopped.
Frequently when patient and study identification information (patient name, patient identification, date of birth, sex, and accession number) are manually entered at a modality, typographical errors occur that have to be corrected before the acquired images can be matched to the proper patient and study on a picture archiving and communication system (PACS). The Digital Imaging and Communication in Medicine (DICOM) Modality Worklist service alleviates these problems by automatically transferring this data from the radiology information system (RIS) to the image acquisition modality. The technologist then does not have to manually re-enter the data to place it into the image files. With modality worklist, precise patient and study data are obtained and placed into the image headers with no typographical errors. When the images are sent to the PACS, they match the corresponding patient and study records, and are immediately incorporated into the electronic patient record. While modality worklist does replace the manual keying of the data and virtually eliminates typographical problems, it introduces a new source of human error: the incorrect selection of the patient and/or study from the computerized worklist, and the resultant mislabeling of the images. When these mislabeled images are sent to the PACS, they are immediately associated with the wrong patient and/or study, where they potentially may cause serious harm. The goal of this report is to raise awareness to this problem, to identify the major causes of these errors, and to offer some practical suggestions on how to minimize them.
Physicians need to be proficient in their use of CPT codes and ICD-9 codes. They must participate actively and be knowledgeable of their billing process. An organized approach to coding and billing has been suggested by the American Academy of Pediatrics, as outlined in the following box. Physicians are ultimately responsible for any bill submitted in their name. Therefore, close scrutiny of the coding and billing procedures is paramount. Even if mistakes are made in the billing process beyond physicians' input, physicians still may be held responsible. If physicians do their own coding, the bills become more accurate, which can result in higher reimbursement. Physicians also should have a functional compliance plan in place, whether practicing in a large faculty group practice or practicing solo, with the ability to audit the coding and billing process and respond to variances if they are found. By being more involved in the process, physicians can have a more efficient billing system that avoids the potential for fraud and abuse and improves collections.