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Maintaining Accuracy and Compliance in the Medical Record
Why is accuracy and compliance to accepted standards of documentation in the medical record important? The first and most important reason is to provide patients with appropriate care based on details provided in their medical record. This ensures optimal patient care and allows for excellent patient satisfaction. Another reason for ensuring accuracy and compliance in the medical record is to provide governmental agencies, and any other entity accessing the patient’s medical record accurate and complete information. With improved documentation, collections improve, the risk for unfavorable audit results decreases, and efficiencies are increased in the office with both staff and physician co-workers.
Cheryl L. Carr, COO- Chief Operating Officer
Cheryl Carr began her career in the healthcare industry over 23 years ago as an x-ray technician in an urgent care/occupational medicine facility. She earned a fast-track promotion into Regional Director of eleven medical practice sites in seven different states with a national occupational health provider.
Joyce Ralstin, CPC, CCS-P, PMCC-Certified Instructor
As a Regional Director of Client Services with Bill Dunbar and Associates, (BDA), Joyce Ralstin has 25 years experience in the healthcare industry. Prior to joining BDA, Ms. Ralstin served as Billing and Coding Specialist for a large multi-specialty hospital organization employing over 200 physicians.
Janelle Frey, RHIT, CPC, CCS-P
Janelle Frey has over 20 years of health care experience with an emphasis on physician coding, documentation, billing and practice management. Janelle has worked as a Hospital Coding Specialist, a Physician Services Operations Coordinator, and as a Billing and Insurance Director.
Terri Scales, CPC, CCS-P
Terri Scales has over 14 years of health care experience with an emphasis on clinic management, coding and insurance billing, and State Specific Workers’ Compensation Regulation and Compliance. She is an experienced individual with a positive, results-oriented approach to documentation, coding, billing, and reimbursement.
BDA shares its twenty + years experience of documentation and coding with its clients, which often results in their gaining increased revenue, improved compliance, and continued growth.
BDA performs a preliminary analysis of each prospective client's practice by gathering a random sampling of three simple reports; this includes the Chargemaster, Chargeticket/Superbill, and the Fee Profile.
Our Process
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Topics
BDA utilizes several proprietary national fee databases with Geozip specific information, so that it can conduct a comprehensive assessment of your current fee profile.
BDA provides its clients with a detailed summary that identifies key coding issues such as invalid, deleted or revised codes and descriptive changes. A customized Action Plan is developed and implemented over the life of the engagement.
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© 2010 Bill Dunbar and Associates, LLC., all rights reserved. CPT® is a registered trademark of the American Medical Association
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