Wiki Superbill as documentation of injection

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ahight

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Any opinion on the use of an encounter form as documentation of a flu shot & 90658?

United auditor is questioning. Physician did not sign encounter form:(

Thanks,
Andy
 
Hi Andy,
Sometimes a patient would just come in for the Flu shot only. The nurse or who administered the shot should document on the patient's chart where the shot was given on the patient as well as lot number, NDC numbers and any reaction(s) noted after the administration, etc. My opinion is an encounter form is not proper documentation that the flu shot was given. As the old adage goes: "If it wasn't documented, it wasn't done."
 
The nurse always does these types of injections, for documentation look to see if there is an immunization tab or a sheet with a lot # of the drug.
 
encounter form

I would agree. The encounter form is generally not a permanent part of the patient's record, therefore would not be acceptable as documentation. Regardless, in order for the nurse to bill incident to under the physician's number a signature would be required.
 
Superbills and encounter forms are not portions of the patient's health record. As such, those documents serve no purposes outside facilitation of billing/coding functions and cannot be used to support the coding/billing of a service. I know this echos what's already been said.
 
flu vaccine

When a flu injection is given will the form we fill out from the Texas Department of State Health Service be exceptable and enough documentation? Or does it also need to be documented on a separate progress note?
 
you must have the person that administered the injection document in the patient's medical record. regadless of the additional documentation completed.
 
Diagnosis code

Is there a dx code for " h/o psvt?"

thank you in advance
msmaddy:d
 
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