Encounter Forms

dballard2004

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Can anyone please point me in the direction of written guidelines that say that encounter forms must be signed and dated by the physician. We are having a problem at our facility with the physicians signing the encounter forms, but not dating them. I am going to require that all encounter forms be signed and dated, but I need some sort of written guidelines to show that this is required before I can change the policy. Any help appreciated. Thanks.:)
 

member7

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Out of ignorance, can I ask what is contained in an encounter form? Is it like the superbill? Thanks.
 

mmelcam

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I have never heard that the physician has to sign and date the encounter forms. I would be interested in any documentation that anyone has on this.
 

member7

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I too have never seen where a physician is required to sign and date an encounter form or superbill. Is this a CMS requirement? What happens if the encounter form codes are inconsistent with the codes on the 1500 form? Is this something an auditor can penalize the physician for? Is the encounter form a legal record? I hope you get an answer to your question, Dawson.
 

dballard2004

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The problem that I find as an auditor is that the encounter is sometimes inconsistant with the CMS 1500 form. Our physicians are signing the encounter forms, but not dating them. I markoff for this on the audit. Isn't an encounter form considered part of the medical record?:confused:
 

kevbshields

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Dawson:

No, the encounter form is not part of the medical record. In fact, it is suggested that "billing" forms, insurance information and patient accounting data not be stored with the record--as the record is meant to communicate and store clinical information only.

You can pretty much check out any fundamentals of HIM or Medical Records text and it'll tell you as much.

While I'm sure there's some mixed concept of this on local levels, I have to agree with the texts I've read that "billing items" and the health record are different things...
 

dballard2004

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Kevin,

Thanks for the insight! The problem that our sites are having is all of our sites are in other locations (other states) and our billing office is located at our corporate office. Some our billers for those sites that are still paper, all they receive from the site to bill from is the encounter form. They code based upon what the doctor has listed and this is how the date of service is billed. During the audit process, I discover that what is on the encounter form does not match what is in the medical record thus resulting in tons of corrected claims. I realize that this is probaly more of an "education issue" with the physicians, but if the physician is documenting diagnosis on the encounter form, then shouldn't he/she sign and date the encounter stating that they agree with what they are documenting?:confused:
 

whippett

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Our billing mangers states that labs written on the encounter form acts as an order even though the physician has not documented this in our electronic medical record. I disagree with this. Comments please.
Thanks,
Lynn Lowery,CPC
 

RebeccaWoodward*

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Dawson:

No, the encounter form is not part of the medical record. In fact, it is suggested that "billing" forms, insurance information and patient accounting data not be stored with the record--as the record is meant to communicate and store clinical information only.

You can pretty much check out any fundamentals of HIM or Medical Records text and it'll tell you as much.

While I'm sure there's some mixed concept of this on local levels, I have to agree with the texts I've read that "billing items" and the health record are different things...
This is an older link but I actually needed this information as well.

Kevin or anyone that would like to respond,

Is this what you were referring to?

Documents Not Included in the Legal Health Record

Administrative Data and Documents

Administrative data and documents should be provided the same level of confidentiality as the legal health record. However, administrative data should not be considered part of the legal health record and would not be produced in response to a subpoena for the medical record. Healthcare organizations might more appropriately consider some administrative data and documents as working documents.

Administrative data are patient-identifiable data used for administrative, regulatory, healthcare operation, and payment (financial) purposes. Examples of administrative data include:


Abbreviation and do-not-use abbreviation lists
Audit trails related to the EHR
Authorization forms for release of information
Birth and death certificate worksheets
Correspondence concerning requests for records
Databases containing patient information
Event history and audit trails
Financial and insurance forms
Incident or patient safety reports
Indices (disease, operation, death)
Institutional review board lists
Logs
Notice of privacy practices acknowledgments (unless the organization chooses to classify them as part of the health record)
Patient-identifiable claims
Patient-identifiable data reviewed for quality assurance or utilization management
Protocols and clinical pathways, practice guidelines, and other knowledge sources that do not imbed patient data
Psychotherapy notes
Registries
Staff roles and access rights
Work lists and works-in-progress

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921
 

bhaskins1

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Kevin,

Thanks for the insight! The problem that our sites are having is all of our sites are in other locations (other states) and our billing office is located at our corporate office. Some our billers for those sites that are still paper, all they receive from the site to bill from is the encounter form. They code based upon what the doctor has listed and this is how the date of service is billed. During the audit process, I discover that what is on the encounter form does not match what is in the medical record thus resulting in tons of corrected claims. I realize that this is probaly more of an "education issue" with the physicians, but if the physician is documenting diagnosis on the encounter form, then shouldn't he/she sign and date the encounter stating that they agree with what they are documenting?:confused:
I would think that if the encounter form is being used to inform the person responsible for inputing charges then there would have to be a date of service listed. Our encounter forms print with the date of the visit and reason for the visit so our docs just have to check off the services provided and sign the form. If you have providers that are just taking a blank form and filling it in then I would see a need for guidelines as to what has to appear on the encounter form.
 
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