2-1 Discussion: Reviewing Medical Records
I work full time at a medical office so I see electronic medical records a lot, and then patient
referrals, which have the patients full medical record in them. However, the referrals do not really look
like the layout in the example. I wonder if it's because I work in outpatient care and not Inpatient like the
example. I once saw my sons record at an urgent care, and that looked a little similar to the example.
One thing I did see on the medical record that seemed a little outdated was the ICD codes. I did
not recognize the ICD codes, which are now called ICD-10. I’m guessing those codes may be from ICD 9
or older. The ICD-10 codes now used for patient diagnoses have letters in the front for example I50.2 is
congestive heart failure.
I’m a little confused why the charges are listed in the secondary procedure section, without
having any procedures listed. Those procedures would be either noted by name or CPT codes, which you
would see in some form of 1000 – 99999 codes. Also, the charges for 7,236.95 seems a little steep for
someone who has two insurances. Usually if you have two insurances, your fully covered. For example,
Tricare covers 70% and Anthem covers 30%, and then your fully covered.
Some insurances do have a
high deductible but $7,236 seems a bit much and something might not have been billed correctly.
