Wiki encounter forms

[coder1]

Good Morning Coding World!!!


In my current audit , I noticed that the billing system have the correct coding but the encounter form was incorrect according to the notes. The encounter form is generated by the EMR system which produced the wrong codes. Is this ok???

 

[Pam Warren]

Is your encounter form just a billing tool, or is it part of the medical record documentation?

In our world, the encounter form is just a billing tool, and thus we code based on the documentation in our EMR. The encounter form is not part of the legal medical record, and the claim is supported by the medical record only.

You should probably have your IT people look at why the encounter form says one thing and the bill says another. Is the provider overriding the code recommendation by the EMR?

 

[coder1]

The EMR is used by physician for documentation purposes. The encounter form generated by the EMR is based on how the physician document. The problem was the translation from coder and IT (no coding background). The encounter form generated was useless and coders were coding these claims by reading the medical documentation.