-Proper and accurate encounter completion is needed.
-Accurate encounters help with revenue collection and workload credit tracking among other things.
-Telephone contacts , although non-billable, are counted as workload and can affect the budget for your institution.
-’Telephone contact’ cannot be for administrative issues but has to involve medical decision-making
-Telephone contact is “a call between clinical professional staff and patient” to:
If the call was administrative only then enter
-an addendum, -a historical note -or an administrative note
-This includes call to family and even conversations with other professionals on the case.
Steps for Proper Documentation
1-Create a new visit by selecting the ‘correct’ clinic location
2- For Telephone encounters, use a Telephone clinic location
3-This will ensure that No bill will be generated.