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Thread: encounter forms

  1. #1
    Join Date
    Apr 2007

    Default encounter forms

    AAPC: Back to School
    Good Morning Coding World!!!

    In my current audit , I noticed that the billing system have the correct coding but the encounter form was incorrect according to the notes. The encounter form is generated by the EMR system which produced the wrong codes. Is this ok???

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


    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?
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Join Date
    Apr 2007


    The EMR is used by physician for documentation purposes. The encounter form generated by the EMR is based on how the physician document. The problem was the translation from coder and IT (no coding background). The encounter form generated was useless and coders were coding these claims by reading the medical documentation.

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