Encounter form

What is an encounter form?

You may have seen it before. This is the form the doctor attaches to your chart to give to the lady at front desk. This form has your demographic information along with insurance information. 

The office usually picks frequent icd-9 and cpt codes that they use often and preset it on the form. Most of the time the doctor will check off what diagnosis (icd-9) and procedure (cpt) they used and give to the person that will do the charge entry.

  

What is charge entry?

Charge entry is just entering the cpt codes and icd-9. The registration(the patients information, name, date of birth, social security number, address, insurance, etc) is usually already done by someone else who just does registration. 

When you are doing charge entry you enter information that is on the encounter form. Along with the patient demographics, you need to enter the date of service, the cpt code, the icd-9 and the charge amount if needed. Sometimes you need to put in the authorization number or referral information.

  

What is an ICD-9 code?(International Classification Of Disease)

Icd-9 is a diagnosis. The diagnosis is the reason a patient is being seen. For example: a patient comes to see the doctor for a headache. The diagnosis would be headache. A number is assigned to this by a coder. They choose the appropriated diagnosis code from the ICD-9 book and code it on the encounter form.

  

What is a CPT code?(Current Procedural Terminology)

Cpt code is the procedure that is being done. Ex. A new patient comes in to see the doctor for the headache, the doctor examined the patient. The cpt code would be a new office visit. The coder would then choose the appropriate cpt code from the CPT book and code it on the encounter form. 

Examples 99201-99205 are new office visit codes in the cpt book. Depending on how long the patient was seen determines the level and should be done by a certified coder or someone who has experience.

superbill entering - Paper and Electronic Encounter Forms

Charge capture: Paper and Electronic Encounter Forms

Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and diagnosis codes) that describe the service performed. These electronic charging systems have benefits and drawbacks, similar to and different from paper encounter forms.

Keep reading to learn about the benefits and pitfalls of both charging systems, and how to improve them. Why take the time out of your insanely busy week to do this?

Because physician code selection is as accurate as the tool used to select the code: no more, no less.

Let's start with electronic charging.

Beware of abbreviations and shortened descriptions

A cardiologist looked at this description in the drop down box of his EHR.  "EP Consult".  The cardiologist read: Electro Physiology Consult.  The programmer meant, "Established Patient Consult." Do you see the problem with this?  

The abbreviation was open to interpretation, and isn't a standard CPT® abbreviation.  And, consults are not defined as new or established visits, further confusing the matter.  It's true: there is only so much space in the drop down charge entry box.  But, shortened descriptions and abbreviations are an invitation to inaccurate code selection.

How about searching for CPT® or ICD-9 codes?

Searching an electronic data base is not always easy or productive. One group using a diagnosis code look up integrated into their EHR made a major error.  The search term:  confusion.  An elderly patient presented to the hospital, and one of the patient's symptoms was confusion.  

The search engine returned the ICD-9 code for psychosis.  A more accurate code would be altered mental status. This incorrect code--psychosis--was submitted on hundreds of claims.  A psychiatric diagnosis was reported in place of a medical symptom.  Hope it wasn't my mother's claim.

Can't find the procedure code?

What did a physician or NPP do the past when the code wasn't on the encounter form?  Write a brief description, and leave it for the coder.  What does a clinician using an EHR charging system do? 

Too often the answer is bill for an E/M service only, and move on, leaving the service unbilled.  It is critical to have a process that allows the physician to send the record to the coder in this situation.

The case of the missing CPT® book 

A huge pitfall of electronic charging is that the office doesn't buy enough (or any!) CPT® books.  Recently, I was at an office and asked for a CPT® book.  They brought me a 2007 CPT® book and a 2005 ICD-9 book.  Really, those were the most recent editions.

The editorial comments in the CPT® book are critical to correct and accurate coding.  Be sure to read them.  The AMA isn't paying me to say this: buy new books (for CPT®, buy the AMA's Professional Edition) and don't leave them in their plastic wrappers! Paper?

And, oh the joys of the paper encounter form!  Yes, we know there are deleted codes on the form, but we have 10,000 of them in the basement, and they are expensive and our doctor wants us to use them up!  Burn them!  Update your paper encounter form every year.

While you're at it, take out all of the shortened descriptions and abbreviations for minor surgical procedures.  This is the biggest source of errors I find in primary care practices: wrong CPT® codes for minor procedures, linked directly to wrong, incomplete and confusing descriptions of minor procedures, medications, and ancillary services.  

Develop a separate charge slip for these, that lists all of the procedures and services your clinicians perform with their full descriptions.

Remind the MDs and NPPs in your office that they are paid based on CPT® codes, and not on the number of diagnosis codes they circle.  Eight diagnosis codes do not increase the payment for the service.  

It does give the charge entry person heartburn: which of these eight should I list (I can only enter four) and which should be first?  Ask the clinician to number the  most relevant diagnosis codes. Only four. 

Our goal: coding accuracy. One step to achieve it is accurate charging documents, whether on paper or on line. Physician code selection is as accurate as the tool used to select the code. The code is as accurate as the tool: no more, no less.