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Encounter Forms

  1. #1
    Location
    Overland Park, KS
    Posts
    1,166
    Question Encounter Forms
    Exam Training Packages
    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, CRHC, AAPC Fellow
    Coder

  2. Default
    Out of ignorance, can I ask what is contained in an encounter form? Is it like the superbill? Thanks.

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Yes. It is like a superbill.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. #4
    Location
    St. Louis, Missouri
    Posts
    262
    Default
    I have never heard that the physician has to sign and date the encounter forms. I would be interested in any documentation that anyone has on this.

    Melissa Blow, CPC

  5. #5
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Please share if anyone has this info. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. Default
    I too have never seen where a physician is required to sign and date an encounter form or superbill. Is this a CMS requirement? What happens if the encounter form codes are inconsistent with the codes on the 1500 form? Is this something an auditor can penalize the physician for? Is the encounter form a legal record? I hope you get an answer to your question, Dawson.

  7. #7
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default
    The only thing I know about this is that the provider must sign and date the medical record.

    Tina

  8. #8
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    The problem that I find as an auditor is that the encounter is sometimes inconsistant with the CMS 1500 form. Our physicians are signing the encounter forms, but not dating them. I markoff for this on the audit. Isn't an encounter form considered part of the medical record?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  9. #9
    Location
    Louisville, KY
    Posts
    1,101
    Red face
    Dawson:

    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...

  10. #10
    Location
    Overland Park, KS
    Posts
    1,166
    Question
    Kevin,

    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?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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