What is an Encounter Form? 12 Examples of Superbills

If you work with clients or patients in any sort of provider role, you’ll likely need to work with encounter forms, also known as superbills, at some point. They are a vital source of information about what treatment or services were provided to each client, when they were provided, and what category they fall within for coding purposes.

They might seem confusing at first, but the idea is simple! In this piece, we explain encounter forms, review some examples, and provide templates and virtual solutions for your convenience.

Before you start, we think you’ll love our free Quenza 30-day trial. With Quenza’s user-friendly, powerful practice management and treatment planning tools, you’ll have everything you need to take your practice digital today.

What is an Encounter Form or Superbill?

Encounter forms, also known as superbills, are medical forms that document a patient’s visit using codes for diagnoses, procedures, and services rendered.  These codes allow accurate billing and payment processing in clinics, hospitals, and private practices.

Encounter forms are a key aspect of health care, central to client wellbeing, treatment planning, and accurate billing.

How Do They Work? A Closer Look

Whenever a patient or client receives a service, the provider records that service, generally into medical claims software that can automate much of the following process. That process includes coding (procedure codes and diagnosis codes, if applicable) and invoicing/billing and transmission to the patient or client’s insurance company.[1]

It’s vital to ensure that the right information is recorded, both for the client’s health and treatment planning and for accurate billing. This is why encounter forms are such a key aspect of health care.

4 Examples of Encounter Forms in Healthcare

Although encounter forms can differ based on company, facility type, and services offered, they will generally include the following information:

• Patient profile (including patient name, date of birth, billing information, insurance information, etc.)
• Clinical observations (including diagnosis and diagnosis codes)
• Treatment course (including services provided during the visit, examination level, and any other additional services provided to the patient)[2]

Encounter forms can be broad and general to capture a variety of situations, or they can be customized to a specific problem or issue.

For example, the American Association of Family Practitioners offers a toolbox full of encounter forms for various issues, from an acute knee injury to a hypertension evaluation, from a sore throat to a pulmonary embolism screening.[3]

The forms differ by issue type, but they all include these basics:

• Patient’s name
• Age
• Medical record number
• History of present illness
• Physical examination
• Assessment/plan
• Physician’s signature
• Date

Depending on the issue type, the other fields vary.

For instance, the acute knee injury encounter form includes a section on whether the patient experienced a pop or tear with injury, locking of the knee, or the knee giving way, while the hypertension encounter form includes fields for weight, height, BMI, and other major risk factors (like tobacco use, physical inactivity, family history of premature cardiovascular disease, or diabetes).

While the sore throat encounter form collects information on symptoms specific to a sore throat (e.g., history of fever above 100.4 degrees, absence of cough, tender anterior cervical nodes, and tonsillar swelling or exudates), the pulmonary embolism screening encounter form focuses on a different set of symptoms and risk factors (e.g., signs of deep venous thrombosis, a high heart rate, immobilization).

3 Templates & Examples of Encounter Forms

There are tons of templates for encounter forms available to download and print.

For example:

1. This patient encounter form template from Edward Wrighton is available via Jotform. It’s an all-purpose form with fillable fields for the date, patient information, payment method, visit information, category, vitals, fees, and any other applicable information.
2. This encounter form template is designed for an outpatient encounter and has a designated space for the company name, logo, address, etc. It includes fields for patient information, payment method, visit information, category and code of care, type of office visit (e.g., time, new vs. established), supplies used, vitals taken, recommendations or referrals (if any), and any fees charged and copays received.
3. If you’re looking for an encounter form template that’s more suited to mental health care, this template from Marshall University is a great example that checks all the usual boxes. It includes fields for client information, service/needs evaluation, treatment, crisis intervention, case management, client-centered consultation, and any other physician services if applicable.

Digital Solutions: 5 Best Virtual Encounter Forms

The encounter forms above are great for learning about encounter forms or for a small practice where filing and saving individual encounter forms isn’t much of a burden; however, for more established practices or practices with many clients, you’ll want to move to virtual encounter forms and superbills at some point.

Fortunately, there are many healthcare and psychology solutions available for virtual encounter form filling and filing.

If your practice is becoming complex and difficult to manage on your own, the solutions below may be a great idea for your encounter form/superbill needs, plus they have some other helpful features.

Solution	Details
	Kareo features include: Ability to create custom superbills for each provider Library of customizable superbill encounter forms Master list of procedure and diagnosis codes Ability to save and print superbills with prepopulated patient information from the appointment scheduler Ability to print superbills by visit or in daily and weekly batches by provider and location Use superbills to document charges for patient visits Online appointment scheduling Billing and invoicing
Name	Kareo
Price	$80/month and up
Good For	E-therapy, Telehealth, Private Practice Software, Customer Relationship Management, Physical Therapists, Occupational Therapists, Speech Therapists, Mental Health Coaches, Wellness Coaches, Business Coaches, Counselors
Website	https://www.kareo.com/mental-health/

Solution	Details
	Simple Practice features: Simple documentation with auto-populated lists of ICD-10 codes Customizable intake forms, treatment plans, assessments, and more HIPAA-compliant video appointments, including screen-sharing Secure client portal for communication Scheduling (including free, customizable appointment reminders) Intake and documentation functionality Billing, credit card processing, and autopsy Insurance claim filing features (for both primary and secondary claims) Complementary mobile app (iPhone and Android)
Name	Simple Practice
Price	$39 – $59/month
Good For	Coaching Management, Practice Management, Digital Health, Telehealth, Telepsychology, E-Mental Health
Website	https://simplepractice.com/

Solution	Details
	Solution features: Customizable patient ledger to track ongoing charges and payments Ability to create invoices and superbills Built-in customer relationship management (including inquiries, referral sources, etc.) EHR (customizable assessments, treatment plans, group notes, and note templates) Outcome measure tracking Patient portal with safe and secure information sharing Patient calendar to track cancellations, no-shows, notes, and billing codes HIPAA compliant telehealth Medication management and e-prescribing Human resources functionality (track employee files, emergency contacts, CEUs, employment applications, etc.) No set-up fees Unlimited data
Name	BestNotes
Price	$50/month and up
Good For	Therapy Notes, General Healthcare, Telepsychiatry, Physical Therapists, Occupational Therapists, Speech Therapists, Mental Health Coaches, Wellness Coaches, Business Coaches, Counselors
Website	https://bestnotes.com/

Solution	Details
	TherapyNotes features: Customizable form templates and superbills with only a couple of clicks Electronic claims filing and status tracking Interactive calendars and integration with other calendars Appointment scheduling and automated reminders Billing, invoicing, and payment processing Customizable client portal Templates and customizable client notes Secure videoconferencing Secure Messaging
Name	TherapyNotes
Price	$49 – $59/month
Good For	Coaching Management, Practice Management, Digital Health, Telehealth, Telepsychology, E-Mental Health, Mental Health Coaches, Wellness Coaches, Business Coaches, Counselors, Teletherapists, E-counselors, Online Coaches
Website	https://therapynotes.com/

Solution	Details
	TheraNest features: Easy to create, print, and email invoices and superbills Ability to print, email, or add multiple invoices to claims awaiting submission Batch invoicing and batch statements Appointment scheduling and reminders Billing, payment processing, statements Practice management reports and statistics Client portal for scheduling, payments, cancellations, etc. E-prescribing functionality EMR/EHR Custom forms and assessments Secure provider-client messaging
Name	TheraNest
Price	$39/month and up
Good For	Practice Management, Physical Therapists, Mental Health Coaches, Wellness Coaches, Counselors, Teletherapists, E-counselors, Online Coaches
Website	https://theranest.com/

Benefits of Using Digital Encounter Forms

The healthcare industry has increasingly adopted digital technologies to enhance efficiency and accuracy in recent years. Digital encounter forms, or electronic superbills, offer numerous benefits over traditional paper forms.

Firstly, they significantly reduce the risk of errors associated with manual data entry. By integrating directly with electronic health record (EHR) systems, digital forms ensure that all patient information is accurately captured and easily accessible. This seamless integration facilitates better coordination among healthcare providers, improving patient care.

Moreover, digital encounter forms streamline the billing process by automatically coding procedures and diagnoses, thus minimizing the chances of claim rejections due to coding errors. Additionally, they enhance security and compliance by ensuring that sensitive patient information is securely stored and transmitted in line with HIPAA regulations.

The convenience of accessing and filling out these forms on tablets or computers also saves time for healthcare providers, allowing them to focus more on patient care rather than administrative tasks. The transition to digital encounter forms represents a significant step towards a more efficient, accurate, and patient-centered healthcare system.

Training Staff on Effective Use of Encounter Forms

Implementing encounter forms effectively in a healthcare setting requires comprehensive staff training. Proper training ensures that all healthcare providers and administrative staff understand the importance of accurately completing these forms and the impact on patient care and billing processes.

Training programs should cover the basics of an encounter form, including its various components, such as patient demographics, service details, and diagnosis codes. Additionally, staff should be educated on common errors to avoid and best practices for accurate data entry.

Hands-on training sessions can be particularly beneficial, allowing staff to practice filling out encounter forms under the guidance of experienced trainers. Providing ongoing training and support is also crucial, especially when updates to forms or coding standards occur. This can include refresher courses, access to updated training materials, and a system for addressing questions and concerns as they arise.

By investing in thorough and continuous training, healthcare facilities can ensure that their staff can use encounter forms effectively, leading to more efficient billing processes, better patient care, and reduced administrative burdens.

Importance of Accurate Documentation in Healthcare

Accurate documentation in healthcare is vital for several reasons. First and foremost, it ensures continuity of care. Proper documentation allows healthcare providers access to comprehensive patient information, crucial for making informed decisions about ongoing treatment and care. This reduces the risk of errors and enhances the quality of patient care.

Moreover, accurate documentation supports effective communication among healthcare professionals. Detailed encounter forms and superbills clearly record patient interactions, treatments administered, and follow-up plans. This clarity helps coordinate care, especially when multiple providers are involved in a patient’s treatment plan, ensuring everyone is on the same page.

Thorough documentation protects healthcare providers from a legal standpoint. Accurate records can serve as evidence in case of legal disputes or malpractice claims. They demonstrate that the healthcare provider followed standard procedures and provided appropriate care based on available information.

In addition to legal protection, accurate documentation is essential for billing and reimbursement. Encounter forms and superbills that are correctly filled out ensure that healthcare providers are compensated for their services. This accuracy minimizes the risk of claim denials and reduces the time and resources spent on correcting and resubmitting claims.

Best Practices for Creating Effective Encounter Forms

Creating effective encounter forms involves adhering to best practices that ensure clarity, completeness, and usability. One key best practice is to design user-friendly forms. Forms should have a logical layout, with sections clearly labeled and organized to facilitate easy completion by healthcare providers. This reduces the likelihood of errors and omissions.

Another important practice is including all relevant fields. Encounter forms should capture comprehensive patient information, including demographic details, medical history, current medications, symptoms, diagnoses, treatments provided, and follow-up instructions. Ensuring that all necessary information is recorded helps deliver high-quality care and maintain accurate patient records.

Regularly updating encounter forms to reflect current medical practices and billing codes is also crucial. Medical guidelines and billing requirements can change over time, and forms should be reviewed and revised periodically to stay current. This helps maintain compliance with regulatory standards and ensures that the documentation supports accurate billing.

It is equally important to train healthcare providers on how to complete encounter forms properly. Providing training sessions and resources can help providers understand the significance of thorough documentation and familiarize them with any form updates. This training ensures consistency and accuracy in filling out encounter forms across the healthcare practice.

Lastly, leveraging technology can enhance the effectiveness of encounter forms. Electronic health records (EHR) systems can streamline the documentation process, reduce paperwork, and improve the accuracy of the information captured. Utilizing EHRs for encounter forms allows for easier access, retrieval, and sharing of patient information, contributing to better healthcare outcomes.

Final Thoughts

If you’re looking for solutions to your documentation and billing needs, many resources exist. If you’d like to stick with physical copies or PDFs for now, you’ll find several examples and templates in this piece.

However, if you’re ready to move on to a more streamlined solution, the five digital solutions above are all great options. They also offer many other useful features to help you take your practice to the next level.

We hope you enjoyed this article. Don’t forget to try our free Quenza 30-day plan for a month of full access to all our software’s practice management features.

Designed by blended care professionals, Quenza will help you streamline your practice and share unique therapy solutions under your own brand, so that you can spend less time on practice management and more time improving your clients’ mental health.

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