Is your encounter form just a billing tool, or is it part of the medical record documentation?
In our world, the encounter form is just a billing tool, and thus we code based on the documentation in our EMR. The encounter form is not part of the legal medical record, and the claim is supported by the medical record only.
You should probably have your IT people look at why the encounter form says one thing and the bill says another. Is the provider overriding the code recommendation by the EMR?
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