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Encounter Forms

  1. Default
    Medical Coding Books
    Our billing mangers states that labs written on the encounter form acts as an order even though the physician has not documented this in our electronic medical record. I disagree with this. Comments please.
    Lynn Lowery,CPC

  2. #12
    North Carolina
    Quote Originally Posted by kevbshields View Post

    No, the encounter form is not part of the medical record. In fact, it is suggested that "billing" forms, insurance information and patient accounting data not be stored with the record--as the record is meant to communicate and store clinical information only.

    You can pretty much check out any fundamentals of HIM or Medical Records text and it'll tell you as much.

    While I'm sure there's some mixed concept of this on local levels, I have to agree with the texts I've read that "billing items" and the health record are different things...
    This is an older link but I actually needed this information as well.

    Kevin or anyone that would like to respond,

    Is this what you were referring to?

    Documents Not Included in the Legal Health Record

    Administrative Data and Documents

    Administrative data and documents should be provided the same level of confidentiality as the legal health record. However, administrative data should not be considered part of the legal health record and would not be produced in response to a subpoena for the medical record. Healthcare organizations might more appropriately consider some administrative data and documents as working documents.

    Administrative data are patient-identifiable data used for administrative, regulatory, healthcare operation, and payment (financial) purposes. Examples of administrative data include:

    Abbreviation and do-not-use abbreviation lists
    Audit trails related to the EHR
    Authorization forms for release of information
    Birth and death certificate worksheets
    Correspondence concerning requests for records
    Databases containing patient information
    Event history and audit trails
    Financial and insurance forms
    Incident or patient safety reports
    Indices (disease, operation, death)
    Institutional review board lists
    Notice of privacy practices acknowledgments (unless the organization chooses to classify them as part of the health record)
    Patient-identifiable claims
    Patient-identifiable data reviewed for quality assurance or utilization management
    Protocols and clinical pathways, practice guidelines, and other knowledge sources that do not imbed patient data
    Psychotherapy notes
    Staff roles and access rights
    Work lists and works-in-progress
    Rebecca CPC, CPMA, CEMC

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  3. #13
    Quote Originally Posted by dballard2004 View Post

    Thanks for the insight! The problem that our sites are having is all of our sites are in other locations (other states) and our billing office is located at our corporate office. Some our billers for those sites that are still paper, all they receive from the site to bill from is the encounter form. They code based upon what the doctor has listed and this is how the date of service is billed. During the audit process, I discover that what is on the encounter form does not match what is in the medical record thus resulting in tons of corrected claims. I realize that this is probaly more of an "education issue" with the physicians, but if the physician is documenting diagnosis on the encounter form, then shouldn't he/she sign and date the encounter stating that they agree with what they are documenting?
    I would think that if the encounter form is being used to inform the person responsible for inputing charges then there would have to be a date of service listed. Our encounter forms print with the date of the visit and reason for the visit so our docs just have to check off the services provided and sign the form. If you have providers that are just taking a blank form and filling it in then I would see a need for guidelines as to what has to appear on the encounter form.
    Barbara Haskins CPC

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