Completing encounter forms

January 29th, 2009 - Codapedia Editor
Categories:   Billing   Collections  

“Collecting the money is out of my hands.”  How many times have we heard physicians express this sentiment, both as wishful thinking and as a statement of fact?    Physicians often overlook the most important step in the billing and collection process:  telling the billing office what services were performed and the correct diagnosis of the patient.  Performing this task well will speed up collections.

Here’s what happens in a typical office if the charge slip isn’t filled out by the physician completely:  The check out clerk must either leave her desk and chase down the answer right away or put it in a folder of charges to be followed up on “later.”  If she steps away from her desk, she leaves patients waiting for her.  She then interrupts the physician to answer the question.  Charges left in the folder to be posted later represent monies not billed or collected.  “When it’s quiet” or “when we get caught up” the check out clerk will call for the medical record, find the information needed to post the charge and then enter the procedure and charge into the computer system.  As well as delaying payment, this adds to the work-load in medical records and for the biller.

What can the physician do:  Take an extra 15 seconds per patient and carefully complete the charge slip.  Make sure that all services provided are checked.  Write down the diagnosis for the day’s visit.  Take the time to notice why charge slips are returned with questions--diagnoses not connected to procedures when multiple procedures are performed, questions about physical exams, post op visits—and fill those slips out more accurately.  Physicians can take 15 minutes a month to ask their billing clerk why charges are denied or can’t be posted from the charge slip. 

Many practices have reasonably tight controls and good billing practices for services provided in the office, however, charges for out of office services may slip through the cracks. The physician should provide the same level of detail (name, diagnosis, procedure code or description of service) as in the office.  The office manager should periodically look at the coding levels for out of office services.  It is not unusual for careful physicians to bill all of their hospital consults or admissions or visits at one level, rather than to take the time to bill appropriately.  It is wise to use any hospital-generated reports (consult notes, OR schedules, ER visit notes) as a double check for charges.  Charges that sit in the pocket of the physician’s lab coat can’t be collected.  If the practice notices wide variation in hospital or nursing home charges from month to month, someone should ask the question: are all of the physicians in the practice submitting their charges on a timely basis?

 

Cash:  Physicians can improve their cash flow by doing their part in the billing process.  The first step is their responsibility:  accurate, complete and on-time completion of charge slips.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association