/policies/,/policies/administrative/,/policies/administrative/uwmf/,/policies/administrative/uwmf/uwmf-wide/,/policies/administrative/uwmf/uwmf-wide/patient-business-services/,

/policies/administrative/uwmf/uwmf-wide/patient-business-services/113014.policy

20150237

page

100

UWMF,

Policies,Administrative,UWMF,UWMF-wide,Patient Business Services

Encounter Forms (113.014)

Encounter Forms (113.014) - Policies, Administrative, UWMF, UWMF-wide, Patient Business Services

113.014

PBS 1: Encounter Forms
Revised: 2-1-05
1

University of Wisconsin Medical Foundation
Patient Business Services Policies & Procedures
ENCOUNTER FORMS


__ __ New __X__ Revised

If Revised, Supersedes Policy Dated: 12-1-04
Effective Date: 2-1-05

Policy Number: PBS – 1
Approved By (Name): Connie Kinsella, Vice President, Patient Business Services


Purpose
To establish a process to assure the development and maintenance of accurate and complete
encounter forms that are maintained on UWMF’s Ventura system.

Policy
1. Department Coding Coordinators shall be responsible for:
 Completing the annual review of encounter forms, per the attached timeline, and
coordinating the annual review with appropriate Clinic Operations coordinators and
managers.
 Promptly notifying PBS, throughout the year, of changes in services, providers, or
locations which need to be reflected on encounter forms.

2. Patient Business Services (PBS) shall be responsible for:
 Maintaining the electronic inventory of all encounter forms, including those
developed by UWHC for sites on PLUE.
 Initiating the annual encounter form review process.
 Tracking the revision date and history of all encounter forms.
 Ensuring consistency in format/design and compatibility with scanning technology
and/or other systems relating to charge capture.
 Printing and distributing all encounter forms.

3. All services furnished to patients by providers must be recorded on an approved encounter
form.

4. All encounter forms shall be updated twice per year: on October 1 to capture ICD-9 updates
and on January 1 to capture all CPT-4 updates. The process of updating ICD-9 codes will
begin in July each year upon receipt of the new ICD-9 codes. The process of updating CPT-
4 codes will begin in October each year upon receipt of the new CPT-4 codes. Coding
Coordinators shall ensure that the most frequently used codes are contained on encounter
forms.

5. Encounter forms will be updated, as needed, throughout the year to reflect changes in
provider, service/procedure code, and diagnosis code information. All proposed changes
must be submitted to PBS via the appropriate Department Coding Coordinator. Updates to

PBS 1: Encounter Forms
Revised: 2-1-05
2
forms used in UWMF managed sites must be approved by the appropriate Clinic Operations
Representative and must be accompanied by a Summary of Changes (attached).

6. All encounter forms shall contain a document number and revision date.

7. A maximum encounter form inventory of one month will be maintained at each site to allow
for interim updates/revisions, as necessary.

8. Format/structural changes to encounter forms should not be made during the annual review
process (August through December).

9. All encounter forms, except lab and radiology, must be printed on white or buff color paper
to facilitate document scanning.

10. All non-PLUE encounter form orders should be placed directly with PBS to ensure accurate
inventory tracking.


Procedure

Annual Review Process
Frequency Reports
1. Each July/August, PBS will prepare, upon request, reports, by Department (i.e., for the
physicians associated with a given scheduling department) detailing the frequency of CPT-4
and ICD-9 use.

ICD-9 Changes
1. Upon receipt of the new ICD-9 books (generally August each year), PBS staff will update
existing non-PLUE encounter forms to reflect deletions in codes and/or changes in code
descriptions for the coming year. Note: PBS staff will not add new ICD-9 codes to the
encounter forms; determination of whether to add new codes will be the responsibility of the
Department Coding Coordinators, working in conjunction with UWMF and/or UWHC clinic
coordinators/managers.

2. PBS staff will also:
 Review all encounter forms for format/design consistency and compatibility with
scanning technology,
 Assign updated document numbers and/or revision dates to each encounter form,

3. PBS staff will distribute the non-PLUE encounter forms, updated for ICD-9 changes, to the
Department Coding Coordinators no later than August 1 each year.

4. Department Coding Coordinators will review the ICD-9 coding changes and update the
encounter forms, as necessary.
 UWMF Forms. For all forms used in UWMF-managed sites, Coding Coordinators
must review all proposed changes with the appropriate Clinic Operations

PBS 1: Encounter Forms
Revised: 2-1-05
3
Representative(s) and obtain his/her sign-off prior to submitting changes to PBS.
Changes are due by August 31.
 UWHC Forms. Changes must be returned to PBS no later than August 31 with
requested changes.

5. The updated forms will be placed in production on October 1 each year. Note: There is no
longer a grace period for ICD-9 changes. All updated codes/forms must be in production on
October 1.

6. Coding Coordinators must complete a summary sheet indicating the changes made to any
encounter form used in a UWMF managed site. This summary must be returned to PBS at
the same time final changes are submitted. PBS will include this summary when delivering
the new forms to UWMF managed clinics.


CPT-4 Changes
1. Upon receipt of the new CPT-4 books (generally November each year), PBS staff will update
existing non-PLUE encounter forms to reflect deletions in codes and/or changes in code
descriptions for the coming year. Note: PBS will not add new CPT codes to the encounter
forms; determination of whether to add new CPT codes will be the responsibility of the
Department Coding Coordinators working in conjunction with UWMF and/or UWHC clinic
coordinators/managers.

2. PBS and UWHC Fiscal Affairs staff will distribute the updated encounter forms to the
Department Coding Coordinators for review no later than November 1 each year.

3. Department Coding Coordinators will review the updated encounter forms and return them to
PBS or UWHC Fiscal Affairs no later than December 1 with requested changes and final
sign-off.

 UWMF Forms. For all forms used in UWMF-managed sites, Coding Coordinators
must review all proposed changes with the appropriate Clinic Operations
Representative(s) and obtain his/her sign-off prior to submitting changes to PBS.
Changes are due by November 30.
 UWHC Forms. Changes must be returned to PBS no later than November 30 with
requested changes.

4. All updated codes/forms must be in production on January 1. Note: There is no longer a
grace period for CPT changes.

5. Coding Coordinators must complete a summary sheet indicating the changes made to any
encounter form used in a UWMF managed site. This summary must be returned to PBS at
the same time final changes are submitted. PBS will include this summary when delivering
the new forms to UWMF managed clinics.

6. Upon receipt of revised encounter forms, all old documents are to be removed from stock.

PBS 1: Encounter Forms
Revised: 2-1-05
4


Interim Review Process
1. Department Coding Coordinators shall notify PBS or Fiscal Affairs staff of any encounter
form format changes or changes required as a result of additions/deletions of providers
and/or service/procedure codes.

2. Within two (2) weeks PBS staff will update the encounter form, assign a revision date, and
will distribute a draft copy to the Department Coding Coordinator for review.

3. Within two (2) weeks, the Department Coding Coordinator will:
 UWMF Forms. Review all proposed changes with the appropriate Clinic Operations
Representative(s), obtain his/her sign-off prior, and submit the final changes to PBS.
 UWHC Forms. Submit the final changes to PBS.

4. Within one (1) week, the PBS will make any final changes needed and send the charge
document to the printer.

7. Coding Coordinators must complete a summary sheet indicating the changes made to any
encounter form used in a UWMF managed site. This summary must be returned to PBS at
the same time final changes are submitted. PBS will include this summary when delivering
the new forms to UWMF managed clinics.


Attachments
Timeline
Department Administrator, Coding Coordinator, PBS Contact List
Clinic Operations Contacts
Encounter Form Change Summary


References
None