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Proper Medical Records and Coding in Billing and Claims Processing

The Nairobi West Hospital entrance: The health facility has been receiving negative public feedback

The world is more and more becoming digitalized and manual records of most things are becoming obsolete, and healthcare has not been left behind in this change.

With the drive and focus towards attaining UHC comes an increased amount of data to be gathered, to ensure that entire populations data in a country are captured in the systems for easy management of the UHC, mainly being spearheaded by governments. Biodata is the least of the problems, compared to data required for billing and claims processing. The higher the population, the greater the risk of fraudulent practices and errors that would expose service providers to liability investigations, with instances of being barred from providing services while investigations are going on.

To avoid such scenarios, Jayesh suggests that there be a sure way of collecting of data once a patient enters the health facility. The information should me stored in the patient’s medical records (virtual or otherwise) and should have details of what the complaint is, what was done/provided and a justification of why it was done and quantities etc. once this is collected. Proper, accurate, precise clinical documentation is very critical in ensuring proper charging for services rendered and therefore is at the very core of what transpires at every department a patient attend. The information collected is coded according to the facility’s coding system, and whether done manually or electronically must be proper captured.

Using the coding system, a patient’s medical condition is captured with details of scope of services rendered. On an e-coding and e-claim system, the codes could easily be inputted prior and the coding officer will just pick based on what is in the patient’s medical records. Jayesh reiterates that the golden rule of healthcare billing and coding departments is,

“Do not code it or bill for it if it is not documented in the medical record.”  He also points out that if the information is not correctly gathered and documented in the medical records of the patient, it would limit access to proper coding; there is also risk of the clinician or over populating the records or entering an erroneous item that would affect what other departments do, e.g. an erroneous drug or procedure when questioned leading to change can lead to erasure or overwriting of records which unless countersigned by the patient can also construed as a fraud case.

Jayesh points out that this would be beneficial in the Kenya context where there has been claims of fraud of high magnitude amongst both the private and public insurers. As the country progresses in the rollout of the UHC, systems must be in place to capture correct information for reimbursements especially where packages shall be used besides the standard per visit capitation payment, otherwise the UHC will bring the NHIF to a place of losses that could lead to failure not just of the UHC but also other services that were there prior to the UHC.