A quick peek at patients’ encounter forms before they leave the office can prevent some major billing problems for your office. The receptionist should scan the encounter form to make sure the information is complete before the patient leaves the office. If the information is inaccurate, that can obviously lead to problems.
Specifically check to see that the provider circled or wrote the diagnosis (ICD-9) codes and levels of service on the encounter form.
What if the form is not completely filled out with a diagnosis code and Current Procedural Terminology (CPT) form indicating the level of service? Ask the doctor or nurse practitioner to complete the form right then. Otherwise, the clinician is going to have trouble remembering six to 20 patients later or at the end of the day what diagnoses or levels of service he or she provided. Of course, the doctor or nurse practitioner can go back and look in the chart to find the diagnosis and supporting clinical documentation, but this will take more time and effort.