Uniformity of Encounter Forms

Title: Uniformity of Encounter Forms 
Standard #:


Issued: 12/01/1997 Reviewed/Revision Date: 08/21/2000, 10/06/2009, 05/05/2011, 04/10/2013, 12/09/2014


USC Office of Culture, Ethics and Compliance, while acknowledging that there is needed variability in encounter forms among clinical departments, requires uniformity of certain core principles.

The broad purpose of the encounter form is for accurate charge capture and to bill professional services.  Each clinical department that bills professional services must use an encounter form or electronic equivalent for data collection and control if not utilizing chart abstraction.

Uniform Data Capture — all encounter forms must include:

  • Patient Name;
  • Patient Medical Record Number (if available);
  • Date of Birth;
  • Date of Service;
  • Place of Service (i.e. Office, Inpatient, Outpatient);
  • Current CPT-4 procedural code and description of service provided;*
  • Applicable modifier information;
  • Resident involvement (if applicable);
  • Current Diagnosis code or diagnosis narrative;
  • Special Billing Instructions: ____________________________;
  • Ample space for documenting the Billing Exception reason (if other than “bill as usual”);
  • Provider Name; and
  • Provider’s Signature and Date.

Physicians (or other providers submitting professional service charges, such as a nurse practitioner or physician assistant) are responsible for the assignment of CPT and Diagnosis codes even if a qualified abstractor is coding the service.

Providers must personally sign all documentation that is used for coding and billing.

Encounter forms must be reviewed annually and updated, if necessary, by each Clinical Department to ensure accuracy of both procedural and diagnosis codes being used.  Encounter form changes and updates must be approved by the Department Administrator.  All clinical departments are encouraged to seek assistance from the USC Office of Culture, Ethics and Compliance should they have questions regarding codes or other required data elements.

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.


*Encounter forms which list evaluation and management (E&M) services must list all code levels for the type of service provided.  It is unacceptable to only have higher levels of CPT-4 codes on the encounter form.