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Superbill as documentation of injection

  1. #1
    Location
    Johnson City, TN
    Posts
    11
    Default Superbill as documentation of injection
    Medical Coding Books
    Any opinion on the use of an encounter form as documentation of a flu shot & 90658?

    United auditor is questioning. Physician did not sign encounter form

    Thanks,
    Andy

  2. Default
    Hi Andy,
    Sometimes a patient would just come in for the Flu shot only. The nurse or who administered the shot should document on the patient's chart where the shot was given on the patient as well as lot number, NDC numbers and any reaction(s) noted after the administration, etc. My opinion is an encounter form is not proper documentation that the flu shot was given. As the old adage goes: "If it wasn't documented, it wasn't done."

  3. #3
    Location
    St.Petersburg, Fl
    Posts
    46
    Default
    The nurse always does these types of injections, for documentation look to see if there is an immunization tab or a sheet with a lot # of the drug.
    Alecia Peck CPC

  4. #4
    Location
    Evansville Indiana
    Posts
    451
    Default encounter form
    I would agree. The encounter form is generally not a permanent part of the patient's record, therefore would not be acceptable as documentation. Regardless, in order for the nurse to bill incident to under the physician's number a signature would be required.

  5. #5
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Superbills and encounter forms are not portions of the patient's health record. As such, those documents serve no purposes outside facilitation of billing/coding functions and cannot be used to support the coding/billing of a service. I know this echos what's already been said.

  6. #6
    Location
    Johnson City, TN
    Posts
    11
    Default
    Thanks everyone! I appreciate the feedback.

    Andy

  7. Default flu vaccine
    When a flu injection is given will the form we fill out from the Texas Department of State Health Service be exceptable and enough documentation? Or does it also need to be documented on a separate progress note?

  8. #8
    Location
    Columbia, MO
    Posts
    12,526
    Default
    you must have the person that administered the injection document in the patient's medical record. regadless of the additional documentation completed.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default Diagnosis code
    Is there a dx code for " h/o psvt?"

    thank you in advance
    msmaddy:d

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