New Encounter: Professional (CMS-1500)

Last updated
Save as PDF

Updated: 10/07/2024 | Views: 15706

Encounters are used to capture information and charges for a patient visit with a provider. The Encounter record includes general information about the visit, the patient’s condition, the parties responsible for payment and the treatment rendered by the provider.

Note:

To aid in efficiency when users create new encounters, System Administrators can set default information under the Encounter Options.
If you are billing for anesthesia services, there are specific settings that must first be configured for Anesthesia Services so that the charges calculate correctly on the encounter.

Encounters can be created using the Professional (CMS-1500) or Institutional (UB-04) claim format. To create an encounter using the Institutional (UB-04) claim format, review New Encounter: Institutional (UB-04).

New Encounter To initiate a new encounter from the: Practice Home window: Click Encounters > New Encounter. The New Encounter window opens then proceed to step 2. Tip: For faster navigation, click the New Encounter icon or press F4 on the keyboard. Find Patient window: Find the patient then click to select > click Create Encounter on the bottom of the window. The New Encounter window opens then proceed to step 2. Edit Patient window: Click Create Encounter on the bottom of the window. The New Encounter window opens then proceed to step 2. Calendar window: Right click on the patient's name and select Create Encounter. The New Encounter window opens then proceed to step 2. Enter information as necessary. Note: Certain information auto-populates depending on the window the new encounter was initiated from, default information set (e.g., in the Patient record or Encounter Options), and the records (e.g., Appointment, Patient, Case) selected in the encounter. Patient section: Enter appointment, patient, and insurance information. Appointment: When applicable, click Appointment to search and select the appropriate patient appointment. Patient: Click Patient to search and select the appropriate patient. Case: The case auto-populates when there is only one case under the patient's record. When there are multiple cases, click Case to select or to create a new case under the patient's record. Prior Authorization: Click Prior Authorization to select or enter authorization information. Primary Insurance: Displays the primary payer within the associated case. To edit the insurance within the case, click the insurance name then click the case. The Edit Case window opens Note: The Secondary Insurance displays when there is a secondary payer in the associated case. If not already selected, click to select Professional (CMS-1500) in the Bill Primary As drop-down menu. Note: The available formats are set under the Claim Formats section of the Encounter Options. If necessary, click to select "Do not send claim electronically" to prevent the claim(s) associated with the encounter from submitting electronically to the payer. Note: For encounters where Institutional (UB-04) is selected to Bill Secondary As, this option is automatically selected and shaded. UB-04 claims cannot be submitted electronically to a secondary insurance.
Dates section: Enter service dates, posting date, and optional batch number. Tip: Entering the Batch # is helpful for running reports when there is a consistent naming convention such as the posting date with the user's initials (e.g., MMDDYYYYAB). Then, when running a report (e.g. Encounters Summary), customize and filter by that specific batch number. Provider section: Enter provider and location information. Scheduling Provider: Click to select the provider who provided services to the patient from the drop-down menu. Note: Auto-populates based on this order; the provider on the associated Appointment record, the Default Rendering Provider on the Patient record, the Scheduling Provider from the patient's previous encounter, or the default Scheduling Provider set in the Encounter Options. Rendering Provider: Click to select the provider used for paper and electronic claims billing from the drop-down menu. Note: Auto-populates based on this order; the provider on the associated Appointment record, the Default Rendering Provider on the Patient record, the Rendering Provider from the patient's previous encounter, or the default Rendering Provider set in the Encounter Options. Supervising Provider: If both the rendering and supervising provider is required by the payer, click Supervising Provider to search and select the provider. Note: Auto-populates based on this order; the Supervising Provider from the patient's previous encounter or the default Supervising Provider set in the Encounter Options. Referring Provider: If applicable, click Referring Provider to search and select the provider. Note: Auto-populates with the default Referring Physician on the Patient record. Location: Click to select the location where services were rendered from the drop-down menu. Note: Auto-populates based on this order; the Location on the associated Appointment record, the Default Service Location on the Patient record, or the default Service Location set in the Encounter Options. Place Of Service: Auto-populates based on the Location selected. If necessary, click to select a different place of service from the drop-down menu. Encounter Mode: Defaults to In Office. To indicate a telehealth visit, click to select Telehealth from the drop-down menu.
Payment section: If applicable, enter a patient payment associated with the encounter. Once the encounter is approved, a Payment record for the patient payment is created. Copay Due: Displays the Copay amount from the primary insurance policy within the associated case. Payment Amount: The patient payment amount. Once entered, additional fields become available. Method: Click to select how the payment is being made from the drop-down menu. Category: Click to select the appropriate category from the drop-down menu if the practice uses categories for certain payment reports. Reference #: The reference number for the payment when applicable (e.g., check number). Memo: If applicable, internal notes related to the payment. When left blank, a note is automatically added to the Payment record that indicates the patient payment date and encounter ID. Procedures section: Enter service line information. Note: Customize the Procedures section as necessary. Mode: Defaults to the ICD codes the Primary and Secondary Insurance accepts. Click to select ICD-9 or ICD-10 as necessary from the drop-down menu. Click the field under a column to enter data. Tip: Enter a question mark (press Shift+? on the keyboard) in the procedure or diagnosis fields to search and select from the codes list. Note: Enter the procedure macro name in the procedure field if the practice uses Procedure Macros. To see the procedure or diagnosis code description, hover over the procedure or diagnosis code. Note: Descriptions display if they have been enabled under the Procedure Lists section of the Encounter Options. To reorder a service line, right click on the service line and select Move Up or Move Down. To remove a service line, right click on the service line and select Remove Procedure.
Hospitalization Dates section: Click the double arrows to expand or collapse this section. If the patient was hospitalized due to a condition related to the encounter. enter the hospitalization Start Date and End Date. Miscellaneous (CMS-1500) section: Click the double arrows to expand or collapse this section. Submit Reason: Defaults to 1. Click to select another code from the drop-down menu only when it is specifically required by the payer. If submit reason code 6, 7, or 8 is selected, the Payer Doc Ctrl # field becomes available. Enter the associated Payer Document/Claim Control Number as required by the payer for claim adjudication. Claim Code (Box 10d): Designated by NUCC. If applicable, enter up to 19 characters to report appropriate claim codes to identify additional information about the patient's condition or claim. Add'l Claim Info (Box 19): Designated by NUCC or by a specific payer. If applicable, enter up to 71 characters to identify additional information about the patient’s condition or claim. E-Claim Note Type: If applicable, click to select the note type in the drop-down menu. The E-Claim Note field becomes available then enter the note to be submitted to the payer as part of the ANSI 837 electronic claim format. Note: Contact the payer to verify requirements for submitting notes as part of the claim. Ambulance section: Click the double arrows to expand or collapse this section. Used only for billing Ambulance Services. Medical and Business Office Notes sections: Availability determined by the type of user currently logged in. If applicable, enter any notes related to the encounter. When finished, do the following as necessary. To perform a code check to validate the claim data against such coding rules dictated by Medicare, Medicaid, National Correct Coding Initiative Edits and other standard coding rules, click Check Codes. Note: This feature can also be enabled to automatically perform a code check upon encounter approval under the Encounter Options. To place the encounter under the Draft status (to be completed), click Save as Draft. To place the encounter under the Review status, click Save for Review. To place the encounter under the Approved status and create claims associated with the encounter, click Approve.