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Thread: keeping encounters in pt charts

  1. #1
    Join Date
    Apr 2007

    Default keeping encounters in pt charts

    AAPC: Back to School
    The practice i work for at one time kept the pt encounter in the pt chart. They were told that was a liability due to if audited, the ins. company then had the right to review all payments for this pt(i would think they already know what they paid). I have never work for a practice that kept encounters in charts. I assumed it was to kept financial and medical document separate. Anyway my doc likes them in the chart (he is poor with dictation) so wanted me to see if i could find any info. Thanks!

    Lisa Rust, CPC

  2. #2
    Join Date
    Apr 2007
    Seacoast- Dover New Hampshire


    We file our encounters on a monthly basis. If there is an audit I believe that they look at the note and not the encounter form. Correct me if I am wrong.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Join Date
    Apr 2007


    Many of the doctors I work with keep encounters in the chart. In fact all of the EMR systems I have worked with are setup this way.

    I don't see where it would be a liability unless the bill looks nothing like the encounter form, then someone could get in trouble if they were upcoding or changing dx that were not supported. But that would be an issue regardless of access to the original encounter sheet.

    Insurance companies ultimately don't care what our internal charge sheets say. They care about the bill they actually get and the documentation that supports it.

    Now that is not to say they couldn't find information on there that would not be good for the practice if it was seen by the insurance company. But if that is the case the issue shouldn't be how to avoid getting caught you need to take the steps in order to fix the problem so it is no longer something that you feel needs to be hidden.

    Just my opinion. I know there are some auditors that work for insurance companies that read and respond to posts on here, hopefully they will chime in as well.

    Laura, CPC, CEMC

  4. #4
    Join Date
    Apr 2007
    Charleston, South Carolina


    I have been told many times, and by two healthcare lawyers that practicies should always keep the financial records separate from medical records. As this has been a while, I dont recall the specific reason, but do remember it made sense at the time. I may have a reference at home and will look for it.
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

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