If you work with clients or patients in any sort of provider role, it’s likely that you’ll 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 a simple one! In this piece, we break down what encounter forms are, go over some examples, and provide templates and virtual solutions for your convenience.
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What is an Encounter Form or Superbill?
Encounter forms, also known as superbills, are: “Document services rendered by capturing the diagnosis and procedure codes, which serve as the basis for billing and receipt of payment for services.”
Encounter forms are a key aspect of health care, central to client wellbeing, treatment planning, and accurate billing.
Whenever a patient or client receives a service, that service is recorded by the provider, generally into medical claims software that can automate much of the process that follows. That process includes coding (procedure codes as well as diagnosis codes, if applicable) and invoicing/billing and/or transmission to the patient or client’s insurance company.
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)
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 a variety of issues, from an acute knee injury to a hypertension evaluation, from a sore throat to a pulmonary embolism screening.
The forms differ by issue type, but they all include these basics:
- Patient’s name
- Medical record number
- History of present illness
- Physical examination
- Physician’s signature
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).
And while the sore throat encounter form collects information on symptoms specific to a sore throat (i.e., 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.
- 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.
- This encounter form template is designed for an outpatient encounter and has designated space for 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.
- 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 the 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 getting complex and difficult to manage on your own, the solutions below may be a great idea for your encounter form/superbill needs, plus some other helpful features.
|Kareo features include:|
|Price||$80/month and up|
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|Simple Practice features:|
|Price||$39 – $59/month|
|Good For||Coaching Management, Practice Management, Digital Health, Telehealth, Telepsychology, E-Mental Health|
|Price||$50/month and up|
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|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|
|Price||$39/month and up|
|Good For||Practice Management, Physical Therapists, Mental Health Coaches, Wellness Coaches, Counselors, Teletherapists, E-counselors, Online Coaches|
If you’re looking for solutions to your documentation and billing needs, there are many resources out there. 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 that can help you take your practice to the next level.
We hope you enjoyed this article. Don’t forget to try our $1 Quenza 30-day plan, for a month of full access to all our software’s practice management features.
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- ^ Harris, S. T., & Kulesher, R. R. (2009). The importance of encounter form design. The Health Care Manager, 28, 75.
- ^ GSK. (n.d.). Coding via the medical encounter form. Retrieved from https://www.gskvaccinescodes.com/coding-via-the-medical-encounter-form.html
- ^ Edsall, R. L. (2006). The FPM encounter forms collection: ‘Paper automation’ of your progress notes. Family Practice Management, 13, 63. Retrieved from https://www.aafp.org/fpm/2006/0900/p63.html