What is an Encounter Form or Superbill? Encounter forms, also known as superbills, are: “Document services rendered by capturing the diagnosis and procedure codes, which serve as the basis for billing and receipt of payment for services.” [1]
If you work with clients or patients in any sort of provider role, it’s likely that you’ll need to work with encounter forms, also known as superbills, at some point. They are a vital source of information about what treatment or services were provided to each client, when they were provided, and what category they fall within for coding purposes.
Although encounter forms can differ based on company, facility type, and services offered, they will generally include the following information: Patient profile (including patient name, date of birth, billing information, insurance information, etc.)
This document is called the: Remittance advice.
The type of insurance plan that promotes quality, cost-effective healthcare by monitoring patients, encouraging preventive care, and requiring performance measures of physicians is known as: managed care .
CPT codes are used to capture the face-to-face time spent between a patient and the care provider.
This form is called a Superbill, and is otherwise known as what?
ICD-9-CM no longer meets the needs of healthcare organizations.
Although encounter forms can differ based on company, facility type, and services offered, they will generally include the following information: Patient profile (including patient name, date of birth, billing information, insurance information, etc.) Clinical observations (including diagnosis and diagnosis codes)
[1] Encounter forms are a key aspect of health care, central to client wellbeing, treatment planning, and accurate billing.
For instance, the acute knee injury encounter form includes a section on whether the patient experienced a pop or tear with injury, locking of the knee, or the knee giving way, while the hypertension encounter form includes fields for weight, height, BMI, and other major risk factors (like tobacco use, physical inactivity, family history of premature cardiovascular disease, or diabetes).
It’s vital to ensure that the right information is recorded, both for the client’s health and treatment planning and for accurate billing. This is why encounter forms are such a key aspect of health care.
Whenever a patient or client receives a service, that service is recorded by the provider, generally into medical claims software that can automate much of the process that follows. That process includes coding (procedure codes as well as diagnosis codes, if applicable) and invoicing/billing and/or transmission to the patient or client’s insurance company.