How to Design and Use Your Own Encounter Forms

Information on using encounter forms designed especially to meet your needs, plus an example...

One of the most important parts of a medical coder's job is to enter the specific codes from a medical encounter into your medical claims software.

If you're working in a doctor's office, these codes will most likely be assigned by the doctor, as he or she is performing the office visit.

An encounter form is exactly what it sounds like. It's the record of the codes assigned by the doctor during a patient encounter. This is the information that the medical coder uses to enter codes from a patient visit and send a claim.

Many doctor's offices design specific forms, sometimes also known as superbills, on which all commonly used codes are listed on a single sheet of paper.

This paper is printed with all the necessary patient demographic information, including any necessary claim numbers and insurance information.

The doctor uses this form during the office visit to record the procedures performed, such as the office visit code, as well as the patient's diagnosis. Any nurses involved in the patient's care may also record necessary procedures performed, such as lab tests.

Once the doctor is done, he or she gives one copy of the form to the front office staff or directly to the medical coders.

The medical coder's job is to get the form after the patient's visit and record all of the procedure and diagnosis codes. They enter this information into the medical billing and claims software, and the claim is electronically sent to the patient's insurance company.

Double-checking the encounter forms

An encounter form

One of the medical coder's more important jobs is to double-check the forms, to make sure nothing has been missed by either the doctor or the nurse.

Medical offices can get very busy sometimes, so much so that both the doctors and the nurses will forget to code simple things on the forms.

In order to ensure that nothing has been missed, the coder has to be diligent about noting the reason the patient came into the office (well-child exam), and what is said to have been performed at the visit (an evaluation and management service and three vaccines).


If the patient comes in for a well child exam, and the only code noted is a sick visit code, the medical coder has to check to make sure the claim was coded correctly.

In this case, perhaps, the child came into the office for a well child exam, but turned out to have a strep throat infection. So all that was performed at the office visit was a sick visit and a strep screen.

After all the codes are double-checked, the coder can enter the claim into the computer.

Why design your own encounter forms?

Designing your own encounter forms can increase productivity

There are many pre-made forms, each listed with special codes for each specialty. So why design your own?

It's not as difficult as it may seem. You can order pre-printed, double-paged forms, with one copy for your office and the other for the patient, designed with your own specific code sets.

You can also design a form as simply as possible, with easy word processing software. Your medical billing software may also have the possibility of designing and printing encounter forms for patients with scheduled appointments.

It's also a necessary part of making sure you understand the codes for which you commonly bill, and be able to change these whenever necessary.

Designing your own forms and constantly changing them as needed is an important part of being an active and concerned medical coder.

Designing especially for your office and doctor

An easy way to make sure that your doctor and nurses code the claims correctly (even when they're very busy) is to design the forms specifically to meet their needs.

You need to sit down with the doctor to determine:

  • what diagnosis codes they use the most
  • any specific procedure codes that they perform very often
  • how the encounter form can be designed to better meet their needs.


A paediatrician

In a pediatrics practice, doctors give many childhood vaccines.

To make sure you're coding vaccines correctly, it's necessary to design the encounter form to include all the vaccines that the office gives, and order them in addition to the vaccine administration codes.

This is to make it as easy as possible for the doctor to quickly circle the right vaccine codes.

In an ear nose and throat office, however, there's very little need for common childhood vaccines. Instead of including these on your encounter forms, include common evaluation and management codes and commonly performed procedures, such as tonsillectomies.

Designing especially for your billing and coding needs

It may also be necessary to design your encounter forms to meet the needs of your medical billing and coding staff. You can include little reminders to make it easier for coders to code patient visits correctly.

For example, in a pediatrics office, it may be necessary to include a small place for the doctor to include a number of units next to vaccine administration codes, just to make sure that the coder includes the right amount of vaccine administration codes.

In other specialties, it may also be necessary to include a modifier reminder, when certain codes often need a modifier in order to be paid correctly by the insurance company.

No matter how you design your forms, or in what format, it's important to include all of the necessary procedure and diagnosis codes on an easy to read and understand, single-paged document.

Being an active voice in the way encounter forms are designed and used is an important part of making your job as a medical coder is done right and as time-efficiently as possible.
