Hi,
I got a question for you all amazing charts experts. We are seeing more and more patients everyday, and need to way to close out the amazing charts superbill as the patient checks out even though the doctor and the nurse will have a bunch of charts in their inbox with things that need signing off. This questions especially goes out to all you office managers out there.
We have tried several different ways of doing this without success.
1) Putting charges in as soon as the patient leaves with the chart still in the Doctor's inbox. (This was putting the old diagnosis codes on the statement at the end of the day.)
2) After the Doctor signs off going back in and letting the nurse put in the immunizations after the patient leaves. (This was putting the vaccines in the summary page but not the visit. We have to have it show up in the visit for insurance audits.)

Any other suggestions will be greatly appreciated.

Thanks,
Maranda

The only piece of paper we use is a printed charge slip which has my most common diagnosis codes on the top half and the most common procedure codes on the bottom half and a section for when the next appointment needs to be or if surgery, x-rays etc need to be scheduled. The MA puts it on a clipboard in the exam room with the patient.
At the end of the encounter I check off the appropriate boxes ( or write it in a blank space if needed)and give the paper charge slip to the patient who takes it to the front desk where her prescriptions, lab and other orders and instructions have been printed out, appointments are made etc.
I do not try to sign the chart immediately ( unless it is a very simple visit) but forward it to myself. I review the charts later when I do not have the pressure of waiting patients before I sign it. This helps my accuracy, and when I have signed it the gal who does the billing crosschecks the paper charge slip against the AC note for accuracy and then submits the charges.
If the patient needs an injection I send a "red " message to the MA telling her what is needed.
When the MA gives an injection she generates a separate charge slip and creates a separate encounter " Patient needs Injection", puts " Injection ( type of med) given in the (location) by ( her name)in the PE section and forwards the chart with the injection encounter to me for sign off.She has her own templates for these things. This creates two encounters for the patient with correct charges and documentation for the services.
Hope this helps, as the old saying goes there's lots ofways to skin a cat. Or, if there's more than one way to do something then that means there is no perfect way to do it or we would all be doing the same thing.

Good post Deborah.

I make a paper face sheet for all billing - personally I think it is a motivator if you tell the doctor you won't bill until the paperwork is done just like a hospital admit. Worst case is they lose the chart (delete or don't finish), you bill and then a chart audit shows up. Make physicians accountable and I think it will pay off - I try not to wait to do charts, invariably if I do and put the face sheet on my desk it will get shuffled and I won't do it that day.