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Thread: Encounter Forms

  1. #1

    Question Encounter Forms

    AAPC: Back to School
    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.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007


    The encounter forms I am accustomed to, already have the date of service printed on them along with all of the other pertintent patient information. Are you requiring them to hand write the date in addition to the preprinted info?

  3. #3


    Yes. I am going to require them to hand date each one. We have a problem with the wrong date being printed on the form. The physician is signing the form, but not dating them. This is resulting with the wrong date of service being billed. Are there any written guidelines to show that the forms must both be signed and dated by the physician? Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  4. #4

    Default Encounter Forms

    There are two places that I know of:

    CMS Internet Only Manual 100-04, Chapter 12 . Unfortunately, you'll need to scroll through it, I can't cite the exact page by memory, but I do know that it's there.

    Another place you can see the "musts" in terms of documentation is on the first or second page of the E/M Guidelines, in both the 1995 & 1997 versions.

    Also, see if either of these links will lead you to something you can use:
    CMS Signature Requirements: http://www.cms.hhs.gov/Transmittals/...ads/R131PI.pdf


    No guarantees on the links, but hey, nothing ventured, nothing gained, right?

    Good luck! Let us know how you do.

    Leslie J


  5. #5


    Thanks Leslie. You have helped me find what I was looking for. I appreciate your help. Have a great day!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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