Recording the Patient Encounter
Each patient encounter must be recorded in the practice management software with all the information needed to create a claim. This includes linking the encounter to the patient’s existing demographic and insurance information, as well as entering visit-specific details.
Encounter information includes:
- the date of service,
- rendering provider (who provided the care),
- referring provider if applicable,
- place of service, and
- the diagnosis and procedure codes that describe what was diagnosed and what services were performed.
All of this information typically comes from the superbill completed during or after the patient visit.
Verification Before Claim Creation
The billing specialist must verify that all information is accurate and complete before creating the claim. This includes:
- confirming that the insurance information is current,
- that the diagnosis codes support the services billed, and
- that any required authorizations or referrals are on file.