MSRDP COMPLIANCE AND ETHICS COMMITTEE GUIDELINES

Essential Elements of a Billing Document
11/16/00

For the purpose of this guideline, a billing document is defined as the paper medium utilized for data entry of charges into the billing system. Many outpatient sites have begun to use copies of progress or procedure notes as an alternative to the traditional fee ticket or "superbill." This is acceptable if required information for accurate billing is included with the copied note. It is important to understand, however, that it is the original medical record documentation that ultimately supports billed services.

At a minimum, the following information must be included to ensure that services are accurately billed:

1. Patient identification with medical record number
2. Date of service
3. Whether inpatient or outpatient
4. Location with 3-digit IDX code (TDI, Ashford Oaks, etc.)
5. Billing area with 3-digit IDX code (Ophth, Pedi Onc, Vasc Surg, etc.)
6. Referring physician where applicable including UPIN or MSRDP provider #
7. Statement of resident involvement where applicable
8. Physician's encounter note

These elements are suggestions, as each department and/or service may have special needs and should determine other requirements. The use of department/location-specific stamps that include some of the elements listed above is suggested.

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