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nc_coder

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Are the providers required to sign or at least initial the paper encounter forms? They circle the service code and write in the diagnosis. Should they also be signing the form? If so, can you point me in the right direction to find this in writing.
Thank you.
 
I have not heard of this. What needs to be signed is the documentation you are basing your codes to bill off of. When records are requested, the encounter form or superbill isn't sent in to the insurance, just the provider's notes. It's more of a billing document than medical records.

For internal purposes, if you have a generic superbill and multiple providers, it would be a good idea to have them sign/initial them. If you use patient labels or automatically generated info, sometimes the provider listed on that encounter form may be their usual provider, but not the one that saw the patient that day.
 
exactly.. the coding should be based on the documentation in the medical record and that is what must be signed. The encounter slip or super bill is only the item used to guide the patient thru your system it should never be used for coding and submission of the claim.
 
I am unaware of any specific timelines on addenda. It is my understanding, based on best practices, that they should always be made "as soon as possible" after the original entry. A good rule of thumb might be to have the addenda provided as soon as it is realized they are needed.

An internal policy might be best developed in response to what payers or accreditation bodies of your organizations suggest.
 
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