Should You Code from the Encounter Form or Patient Chart?

Q: Is it appropriate to use the encounter form/routing slip to code and bill, rather than to code and bill from the patient chart?
A: This question raises an important distinction between coding and billing. The only way to code a service is from the actual record of the service, but it’s possible to bill from an encounter form if the provider has already coded the service.
It’s important to understand your job responsibility. If you are expected to determine the appropriate code, you must do so from the chart. If you are instead expected to bill the code selected by the provider, the encounter form is all you need. If your role is mixed, the chart is necessary for either coding or code validation.
There is no regulation or statutory rule at issue here that defines these roles, or the responsibilities of administrative staff by role. When the provider is a contracted or “in network” provider, there is usually a contractual obligation that the provider bill the appropriate codes for the medically necessary services performed. How the provider meets that obligation is up to the provider.

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Michael Miscoe

Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA, CEMA, AAPC Fellow, has nearly 30 years of experience in healthcare coding and over 25 years as a forensic coding/compliance expert and consultant. Mr. Miscoe’s law practice concentrates on representation of healthcare providers involved in post-payment disputes. He has an extensive national speaking background and has been published in numerous publications on a variety of coding, compliance, and health law topics.

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