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medical record ?

  1. Default medical record ?
    Medical Coding Books
    Please help me regarding superbills and audits. What is the rule regarding keeping superbills with the chart? My office isn't currently utilizing EMR, but plans to in the future. Now with the charts and when we are on EMR does the superbill with the charged amount need to stay with the chart or can it be filed elsewhere, as long as it is accessable? Currently we have a copy of the superbill inside the chart without the charged amt(only the codes are circled) and a copy with our daysheet with the charged amt.

  2. #2
    Milwaukee WI
    Default Superbill NOT part of patient chart
    The superbill / encounter form / charge sheet is NOT part of the patient's medical record. It should not be stored with the medical record and requirements for keeping the super bills are different and apart from those for maintaining the medical record.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    Thank you so very much! One of my doctors insisted he was ticked for the superbills not being w/ the chart/medical record & I hadn't heard of that before...

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