Medical Transcription Utah | How to achieve Meticulous Medical Transcription? Here are certain vital steps
Medical Transcription has undergone great changes over the past; it is still evolving – the transformation from converting a dictation voice file to a transcript to speech recognition software and directly entering into Electronic Health Records (EHR) has been made possible by innovation in health information technology
Avoid Health Care Hazards and ensure Patient Safety through Accurate Medical Transcripts
Although transcription doesn’t fall under the hazardous category of jobs, it has its share of possible contribution to health hazards – medical transcription, when not performed in the right manner, might give rise to several health risks caused by errors in the documentation of medical reports.
For ensuring patient safety and improving medical care quality, professionals involved in medical transcription process have had to follow certain crucial steps that eliminate hazards and provide reliable documentation.
Crucial Factors that impact quality of medical transcripts
In the modern health care industry, innovative medical information technologies such as EHR and Practice Management Software (PHR) go hand in hand with medical transcription process, thus improving accuracy and effectiveness of records.
A few critical factors that influence the quality of transcripts, and thus, the care quality, are discussed below:
- Accuracy of the data: Information that is free of mistakes or that does not mislead is of paramount importance – reports need to be documented in accurate and precise manner
- Complexity of Patient Situations must be captured: Patients may have complex medical history, surgical procedures may be complicated to document, and narrative about follow up might prove complex – effective documentation of complexity of patient case is essential
- Time management: Documentation of health care reports is a critical process, but physicians’ time spent with patients must not be compromised – documentation process must enable physicians to focus more on their patients
Steps to accomplish flawless and supporting transcripts
The major changes that have rendered the medical transcription process effective reliable have been listed below:
- Digital Recording: Physicians’ dictation now being recorded using electronic means offers flexibility and accuracy
- EHR Software: Patient records can be exchanged easily and various providers can access these with the device of their preference
- Error-free Health records: Accuracy has always been the primary requirement of transcription process – identifying errors proves crucial
- Voice Recognition Software: In place of creating records from scratch, transcriptionists have been enabled to edit and review output from voice recognition software
- Improved training: People who prepare patient notes and create medical records are being extensively trained – increasing productivity and avoiding errors
- Increases quality: Not just TAT, quality expectation of medical transcripts have improved considerably
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How Does Medical Billing Differ From Coding?
Although there are similarities between the two, medical coding and billing are in fact two separate processes. Contrary to common belief by people, they are not one and the same. In both the processes, professionals happen to work in health care setting, gather health information from the patients, and confer with physicians and insurance companies. The similarity ends here.
Fundamental Functions of Medical Coders
Medical coders are entrusted with the determination of the procedures that have been performed by the physician, surgeon, or other member of the health care team. They then assign the diagnosis code or proper procedure code for the corresponding services provided by the medical professionals to the patient.
Medical coders make use of Current Procedural Terminology (CPT) for allocating codes related to procedures received by patients; they refer to International Classification of Diseases (ICD) for choosing the diagnosis code for labeling the concerned physician’s diagnosis about patient’s condition. Coders are expected to assign perfect codes as these will be used as base by insurance providers toward patients’ insurance claims.
What do the Medical Billers do?
Medical billing involves entering codes into specific software and then processing insurance claims. Medical billers use special billing software that lets them enter the codes that are assigned by coder as well as other relevant information- facilitating sending the claim to insurance company for payment.
Entrusted with the process of dealing with insurance providers, medical billers are expected to have complete knowledge of the claims process and all requirements that need to be submitted for processing claims. The responsibility of handing proper insurance claims lies with them too. In this connection, they must ensure that correct billing format is followed, all fields have been answered properly, and all supporting documents are included in the file.
Distinct Processes in Medical Coding
It is the medical coder’s responsibility to decipher documentation of patients’ interaction with care providers such as physicians, surgeons, or nurses – they determine appropriate diagnosis and procedure codes for reflecting the services provided.
Exclusive Tasks in Medical Billing
Medical biller takes the assigned codes along with necessary insurance data, inputs them into the specific billing software, and submits claim to the payer (which is mostly an insurance company) for payment. Moreover, billers need to follow up on the claim as and when required.
To put it shortly, medical coders and billers are entrusted with the task of collecting information, coding claims, and arranging payment for physicians in timely manner. Both these roles are crucial for practice cash flow.