Home Forums Discussions Problems Superbills Without Signing

How are others solving the issue with needing to create a superbill without signing the chart?

Are you still using paper?

Thanks,

S.K.

I treat the superbill in the office just like I do my hospital - until I finish the paperwork the charges are not done. Medicare believes until the H&P, Daily notes, Discharge summaries, etc are done that you should not bill....I agree. If a provider does not have the added incentive of being able to bill only after the paperwork is done then often it will not get done in a timely fashion.

P.S. I use paper - but I finish my charts in the room, only rarely do I forward to finish later and then I hold the superbill until I am done.

I forgot to mention that our office does not accept insurance. Patients pay at the time of their visit - which makes it even more important for us to have a superbill ready for the patient.

Would you guys recommend we continue to use paper? The only other ideas I came up with are:

1) Create superbill before-hand (using "create new superbill" from the patient account section) and date it for the date of the visit - manually enter the CPT & ICD-9 codes. Then when the encounter is signed, elect to not create a new superbill. If the patient cancels or does not show for their appointment, however, the superbill cannot be deleted.

2) Prematurely sign the chart to generate the superbill. Then make edits to the Most Recent Encounter later modifying the Chief Complaint to say something like "FINAL", then re-sign the chart again without creating a new superbill. This makes two entries in the "Past Encounter" section for that date.

What does anybody think?

Thanks again,

S.K.

SLK,
We do accept insurance, but have the same problem with co-pays collected prior to commencement of the note/super bill. (Adding this to the "Wish List" forum.)

I would do a paper superbill. Prematurely signing the chart has a bunch of implications and is messy.

Go ahead and make a superbill. You can go back and correct the superbill to reflect the paper bill information, if they do not match. You should not do it the other way around.

I am in the same situation as SLK. I am evaluating AC now for use in a totally solo home satelite office. I do not accept insurance and would like the ability to complete the chart after the patient has paid and left the office. I find it odd that a program like AC wouldn't allow for this variation. I guess the developers made certain assumptions about how users practice. I would love to hear others' work-arounds before finally taking the plunge

A few assumptions are sort of best practice. For example having more than one chart open at a time. Yes with paper we have a chart open on our desk and lay another over it to answer the phone. Do you ever close a chart up with another chart (or a loose page) inside it? Of course you do, so that is not a best way to do things. IT IS MUCH WORSE with an EMR, with multiple charts open you could chart on the wrong patient VERY easily, so it is a habit we must break.
Signing the chart right away and not finishing the chart later is another habit we have to change. Billing before the chart is finished really is a no-no. Don't fight it, just bend with the flow, I think you will be glad you did. It took me awhile but now I am up to speed with all of this.
As for the superbill, we print out the "face sheet" and for three years we had our staff record the vitals on this and then transcribe to the EMR at a workstation. We used a simple (and cheap) rubber stamp to provide a place on the face sheet for the vitals to be logged in. We went without the face sheet for the past two weeks, and while the staff want to continue to enter the vitals directly into the new laptops, the Doctors have elected to continue having a face sheet, just so we have a "doodle sheet" to enter notes about tests to order, billing numbers etc. I expect we will abandon this sometime in Version 6, but for now, we will continue this hybrid model, it works for us.

I think that as I get used to the system (if I go with AC) I will be able to use all this smoothly. However, as a CAM doc, trust me that at least initially I won't have enough time to complete my note before the patient leaves. The way I work now at my main office, I hand the superbill to the staff and they input the info from the sheet into our practice management software, collect payment, give the patient a receipt and schedule the follow-up. Meanwhile, I am completing my note before I see the next patient. So, I asked the sales person at AC the question about unsigned superbills and he suggested to look at the following link:

http://www.amazingcharts.com/wiki/index.php?title=Create_a_Superbill

I tried this and it does work. I can generate a receipt for my patient with all the necessary info for reimbursement before I sign the note. I call also print a HCFA 1500 this way as well. So I have my answer. As far as I can tell by my experiment, I can then go back to the chart, finish importing items and finish my note after the patient has left and before seeing the next patient. In my solo satelite office, I can perform all these steps and since I don't accept insurance, I am done and actually don't need any other PM software on a link. In the main office we are using Medisoft v 7.0. So thanks to John Gregal in sales!!!

Do I misunderstand, or do you then potentially end up with two superbills per encounter: The one created pre-note, and the one created when you finish your note?

Dom,

I have to agree with Martin completely. I do not think you will find any EMR that completely fits your current style of practice. Rather than the EMR bending to fit you, you must bend to fit it (Within reason. There are still a number of very vital issues that we all would like to see incorporated).

I too first balked at having to complete by notes before leaving the exam room. But then I decided that it was good for the patient to have to sit there and watch me complete all the paperwork required for their encounter. I think it has been eye-opening for them. And, if I am charging for an extended visit, part of that charge is indeed the coordination of care and paperwork required. The patient should be aware of what this entails. If I have to call a consultant, I make the patient wait there in the room.

Also, I now find it is fantastic to be able to fax scripts right from the room, print out info sheets right from the room and complete and sign the chart so that, by the time the patient makes it to the checkout desk, my staff is already on the phone making their mammogram appointments, referrals to consultants, follow up appointments, etc.

So, in summary, you can teach an old dog new tricks....I am proof.

Leslie,

I didn't ever look at it that way. Something to consider. My satelite office will be in my home, basically just 2 rooms, no waitibg area. I prefer to send the patient on their way. By spacing the appointments properly, I can finish my notes between patients. I rarely call consultants, write very few scripts, etc. It is just a different kind of practice. If I can be really effecient with AC at some point, then by all means, I will sign before printing. BTW, is there any way to remove the descriptions of the icd9 and cpt codes from the superbill? Patients only need the code numbers to submit. And what part of the chart does one use to record immunization history?

"I do not think you will find any EMR that completely fits your current style of practice. Rather than the EMR bending to fit you, you must bend to fit it (Within reason. There are still a number of very vital issues that we all would like to see incorporated)."

Leslie, with all due respect...we each have our practice patterns, and some might be demonstrably better than others with regard to outcomes and quality of care. On the other hand, my opinion is that in nearly all cases the EMR should fit what we do rather than the other way around. No EMR can be all things to all people; a specialist may want different features than a primary care provider. A cash practice works better with different work flow than an insurance based practice. The best EMR is one which allows for flexibility. So don't get me wrong...I like AC, but you will never convince me that we are better off without a little box that you can choose to click to print a super before the patient leaves the room.

Alright I cannot stand it....I use a paper superbill and - cannot let go, but open a note and before you finish just go up to add addendum -- open one and type subject office superbill -- put in some tenplate about this note being used to generate billing and close... It should ask if you want to generate superbill --choose yes. Then you can forward note, finish note or whatever.

That should work and make good documentation.

PS if you don't want diagnosis you can uncheck them on bill and only have 99213, etc

Leslie said...
"But then I decided that it was good for the patient to have to sit there and watch me complete all the paperwork required for their encounter. I think it has been eye-opening for them." ( I don't know how you create those boxes that capture someone else's post).
I agree. Part of my motivation for switching to an EMR was the idea of completing the record of the encounter while in the room with the patient. I had grown to hate the end of every day doing 2 hours of charting and thought that it wouldn't hurt the patients to see some of the rest of work that is done to take care of them. To my surprise they haven't fussed at all and don't seem to mind while I enter in the orders, followup, referrals, write Rx, etc. (I don't complete all the details of the history or physical if there are other patients waiting, and forward all of the charts back to myself to check them for completeness before I sign off at the end of the day.) MUCH better than the old days.
I think that AC has helped me organize my own workflow and this old dog is happy for the new tricks.
I admit that I still use a paper superbill. It is on a clipboard that the patient takes to the front desk to receive their prescriptions, print-outs, so forth and pay their bill. This has just about eliminated the patient who used to pocket the prescriptions etc that I had given them and then leave with their superbill walking right out past the front desk.

Maybe tomorrow if the version 5.0.24 I installed this evening works for me I won't be printing RX for them to pick up at the front desk. Then, next, the magic fairy is going to talk directly to Quest and my staff will not be filling out lab requistions anymore, and then..and then...ever sweeter ! Right??

Do you draw for Quest in your office ? I find that if you are sending the pt. to a draw station they will take your order on anything - scrip, order, etc. If you draw in your office they may have a little leverage, but if you speak with your rep about it and discuss other lab options you will probably find that they will be happy to take an AC lab order with demographics on it and not require their req.... please check and report back.

I have been using e scrips for weeks - did you get your authorization back ? Once you get it - it is great.

Jon,

Don't get me wrong. I think there are still many, many things that need to be addressed in AC to make all of our lives better and the ability to customize and produce a superbill is one of those. I have spoken on this adamantly in other posts. But, as you said, "No EMR can be all things to all people". There comes a point where one has to modify some of their old habits in order to use any EMR. And, as I have previously posted, be careful what you wish for. Along with more and more bells and whistles will likely come higher user costs, greater complexity, higher learning curves and loss of that wonderful intuitiveness which led so many of us to choose AC. That doesn't mean you give up wishing for the addition of good, solid basic functionality that will help the majority of users.

Dom,

For recording immunization history, go to the Summary window. If they were given somewhere other than your office, you can denote it there as well.

Deborah, just click on "Quote" at the bottom of the message you want to quote and delete what you dont want.

Oh. Alice wants to complete the chart in the room . But she has difficulty getting the patient to shut up. "Oh and one more thing..." No matter what she says they won't stop. So she has a paper "orders" sheet and she sends them with it to the front desk.

Yes...I have that, too. Sometimes it is "one more thing" and sometimes it is discomfort with sitting in silence; they just want to "make conversation". If they are going to stay and chat, I prefer to have them talk to my staff while I get my paperwork done.

Thanks Leslie

JBS, I wholeheartedly agree!

I also try to finish the note while the patient waits. If they want to chat, and I can't concentrate, then I make an excuse to go to my desk and finish it there. I print paper Rx's and hand them to the patient myself, and complete all but 2 or 3 charts per month at the time of service. Inevitably there will be a piece of critical information, (call back from a consult, etc) that I elect to wait for and in those cases I would have no superbill if I needed it.
As I have posted else where I agree one size does not fit all, and picking the EMR with the closest fit is your first priority. But then I am in complete agreement with Leslie, don't wish for the EMR to be TOO flexible or it will become so flexible that it is bloated, slow and no longer intuitive. (which is my impression of eClinical).
I stick to my opinion however that the goal for all of us is to have the note completed in the presence of the patient at the time of service. The other extreme, completing your note days or weeks later we all know is "medical fiction". I am moving ever closer to every note completed in the presence of the patient and every variable accommodated by a new appropriate entry.
I have templates for the chief complaint that state: "As a consequence of lab results:" or "The Hospitalist States:" or "Patient telephone call:"
Then in the HPI I relate the facts and I now have the Assessment and Plan to allow me to record a new diagnosis (Acute MI per the Hospitalist) or (Acute Pharyngitis from the patient phone call) and I can generate the Rx for Amoxicillin or the request for Cardiac Rehab. In the case of something major like a surgery or the MI, I make an entry right now in the Past Medical History. I sign this note, but generate no bill (but dream of the day...)and find that this note gives me an easy method of keeping track of what is going on. When the patient shows up in my office, (sometimes a long time after the MI if it is an HMO patient who has a complicated course)I can see the notes, see the authorizations or any meds we refilled etc and have a pretty clear idea what is going on.

We are a CAM practice, too, so that's where my concern is! It sounds like DomMasiello, that you are considering doing Option #1 that I listed in my second post, and that it will work out well for your practice. It sounds like we should just try that as well since signing the note prematurely can have some other undesirable effects.

Any answer to the question on how to get your NPI and Tax ID to show on the superbill and prescriptions? I may post another question to the main Problems board.

Thanks for all your thoughts, folks!

- S.K.

The other option is to generate a superbill in the letter writer - that way you can have a template that lists all the pertinent information you want included - Tax ID, NPI, address, etc. Could then have a template with codes you want, etc - just another option from doing the addendum with a superbill.

You know folks one way to look at it is this - if AC allowed importation of documents in multiple formats, if, in other words, it had more than a rudimentary word processor, then maybe I would have the time to finish the chart before the patient leaves. As it stands the limitations of AC and the needs of my CAM practice leave me no choice right now but to generate a superbill before finishing my note.

I guess my question is what does importing forms, etc have to do with finishing the note ? You can always have forms, etc in any format and import them and just reference them in your note.

Have you tried any of the above to generate a superbill? There appear to be more than one option that may be viable - using the letter writer allows you to put anything you want on your bill - it can even have multiple paragraphs about billing, office information, etc. - the addendum with superbill allows you to generate with standard CPT and ICD 9 codes.

I import data from another program I use for CAM. AC destroys the formating of that document which is part of HPI. Now I have to open Word cut and paste to Word then paste from Word to AC WITHOUT formating!!!! My practice is not like yours. I can't put everything into an addendum it just doesn't work. As I said before every doc has to adopt and adapt. I'm just trying to make it work for me.