Medical Records Basics
What’s the first document usually created when a patient visits the ER after a crash?
Intake/triage or ER admission note.
What does CPT stand for?
Current Procedural Terminology.
Who usually provides the first medical treatment after a motor vehicle accident?
Emergency room doctor or paramedic.
Why is a gap in treatment a red flag in PI cases?
Defense may argue the injury wasn’t serious or caused by the accident.
What is the case manager’s first step after opening a new file?
Review the file
This type of record summarizes the most important highlights of the entire hospital stay.
Discharge summary.
The code set used to classify diagnoses is called?
ICD (International Classification of Diseases).
This type of provider specializes in treating soft tissue injuries after accidents.
Chiropractor or physical therapist.
If medical records show a “pre-existing condition,” what should a case manager note?
Whether the accident aggravated the condition.
Why must case managers review bills before sending to the attorney?
Why must case managers review bills before sending to the attorney?
What does “HPI” stand for in medical records?
History of Present Illness.
If a bill lists “balance due $0.00,” what might that indicate?
It was covered by insurance, written off, or still needs provider confirmation.
Why might an orthopedic surgeon’s notes be critical in a PI case?
They can recommend surgery or confirm permanent impairmen
What’s the issue if the client denied prior injuries but records show otherwise?
Credibility problem; must be clarified with attorney/client.
What should you do when sending a medical bill/record request to a provider
Send HIPAA authorization promptly; follow up regularly.
Name two things a case manager should look for in ambulance reports.
Mechanism of injury, complaints, vitals, or loss of consciousness.
Why is it important to confirm the provider’s billing address?
To request updated bills and avoid delays in demand package prep.
If a client sees multiple providers, what should the case manager do to keep records organized?
Track and request bills/records from each provider; maintain treatment chronology.
Why is inconsistent pain reporting across visits a problem?
Defense may claim exaggeration or lack of injury.
Why should a case manager compare records and bills together?
To confirm charges match treatment provided
What is the difference between objective and subjective findings in a medical record?
Subjective = patient reports (pain, symptoms); Objective = provider observations/tests (imaging, exam findings).
What’s the difference between billed charges and liens?
Billed charges = full provider bill; Lien = provider’s claim for repayment from settlement.
A treating doctor recommends “future care.” Why is this significant?
Supports claim for future medical expenses in settlement.
Name two billing red flags that could weaken a demand.
Duplicate charges, unrelated treatment, excessive costs, or miscoding.
In preparing a demand package, how should medical bills be summarized during the Demand Prep Stage?
In a medical specials chart: provider, dates, charges, balances, liens.