PROGRESS NOTE
CORRECTIONS FOR
CLINICAL STAFF
CLINICAL CORRECTIONS 11/2017
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Share of Cost/UMDAP:
Share of Cost/UMDAP may impact a program’s ability to make progress note corrections. In most
situations, once Share of Cost is cleared, a program will need to follow instructions below as if the
encounter has been claimed to the State.
Billing Activity:
If you identify an encounter that is final approved and has billing activity but has not claimed to Medi-
Cal, please contact MHBU for instructions.
Billing Void, Replaces, and Deletion:
Refer to the Financial Billing Manual for additional instructions when submitting the Void, Replace, or
Deletion forms.
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TABLE OF CONTENTS
Table of contents……………………………………………………………….
2
Individual progress notes……………………………………………………..
3
Basic flow chart of correction process…...………………………………..
4
Clinical correction matrix……………………………………………………….
5
Encounter did not occur…………….. ………………………………………..
7
Wrong client chart/Wrong date of encounter……………………………….
7
Duplicate progress note & encounter…….………………………………….
7
Change encounter to never billable activity……………….…………………
8
Change non-billable service code to informational note……………………
8
Wrong or insufficient information in the client narrative……………………..
8
Wrong billing indicator which affects billing ....………………………………..
9
Wrong billing indicator which does NOT affect billing..……..……………….
9
Wrong service code……………………………………………………………….
10
Time data entry error…………………………………………………………..…
10
No active client plan OR progress note final approved after 14 days….……
11
Change service code to a non-billable service code…………………………..
12
Multiple scenarios………………………………………………………………….
12
CLINICAL CORRECTIONS 11/2017
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Introduction to Individual Progress Notes
Individual Progress Notes within CCBH have distinct portions which connect the narrative of the note
with an encounter (service), as well as objectives in the client plan. Due to the connection between
different portions of the product, making corrections to any portion of the note can be different
depending on the status of each of the areas.
The progress note correction process will take collaboration amongst administrative staff, MHBU,
Optum Support Desk and clinical users. Please make sure all staff who touch encounters or progress
notes have access to the correction packet for reference.
Individual Progress Note FAQ Basics
When can a progress note be deleted?
• A progress note may be deleted only before it is final approved. Once the note is final approved
it may not be deleted. Voiding the note is the only option. Voided progress notes will always
remain in the system and will show as “VOIDED.” If you want to view voided progress notes,
please review your filter settings and change accordingly.
What can I change on a progress note and when?
• Once a note is final approved, nothing can be changed. If you need to update the narrative and/
or the encounter, a void & replicate with the Optum Support Desk would be necessary.
• The encounter includes all aspects of the service: client assignment, service time, travel time
and documentation time, as well as the billing indicators and diagnoses (DAS). Once an
encounter has been batched (or pulled for billing) with the MHBU, no portion of the encounter
can be changed. Users must wait for the original encounter to be paid or denied by the State
and then void, delete, or replace with the MHBU.
• The date of the encounter and selected client cannot be changed once the progress note is
opened. Double check the client name and the date of encounter before doing any data entry.
What can I do to prevent the need to void a progress note?
• Double check the client name and the date of encounter before doing any data entry.
• Double check the intervention at the time you enter it into the encounter AND if it is a planned
encounter, make sure to select it in the Related Client Plan section of the progress note.
• Double check the server, billing indicators, assignment, and diagnoses (DAS). Do not save the
encounter until you have verified the correct server, billing indicators, assignment and diagnosis
(DAS).
• Double check the content of the progress note. Make sure it supports the intervention and
service entry. Do not final approve the note until you have verified all the encounter information
and the content of the note. Only final approve when you are certain the note is complete.
What needs to be checked before I request a progress note to be voided or void & replicated?
• Check to see if the note is final approved. If it is not final approved, it may be deleted or edited.
If it is final approved, a void or void & replicate may be necessary.
• Check with your administrative staff to check the billing status. If the encounter has been
batched or is paid or denied, the encounter may not be edited. If it is still unclaimed, users may
call the Optum Support Desk to void/void & replicate the note.
• If you have questions on any of the corrections process, call the Optum Support Desk BEFORE
you try to fix it on your own.
CLINICAL CORRECTIONS 11/2017
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It’s determined a progress note correction is needed...
Administrative staff check the claim status
Unclaimed
Claimed
Call the Optum
Support Desk to Void
or Void & Replicate
the Progress Note
Follow the steps on
the matrix to complete
the correction process
Paid/Denied
Enter a 998 service
utilizing the same
form number/
encounter ID
Run 998 report to
monitor the status
of the claim
Once the service is
paid/ denied, submit
appropriate form to
MHBU
Once you have been
notified from MHBU the
VOID/Replace has been
processed, delete the 998
service
Notify the clinical staff
the correction is ready
to be completed
Submit appropriate
form to MHBU
Once you have been notified
from MHBU the
VOID/Replace/deletion has
been processed, notify the
clinical staff the correction is
ready to be completed
If needed, call the
Optum Support Desk
to Void or Void &
Replicate the Progress
Note
Follow the steps on the
matrix for type of error
to complete the
correction process
Follow the steps on
the matrix to complete
the correction process
Clinical
Administrative
Legend
**This will be the process for MOST progress note corrections, please consult the matrix or the Support Desk before making any edits.
Identify the type of
error
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The following pages will outline specific scenarios and will direct you to the correct action steps. Each of
the action steps are outlined step by step in the appendix and are meant to walk you through the
process. If at ANY time you cannot move forward with the included instructions, please contact the
Optum Support Desk for assistance. If an encounter is non-Medi-Cal or has billing activity (such as
share of cost or other health coverage), contact MHBU for specific instructions.
Encounter did not occur
If the encounter documented did not occur and was entered in error and the note is:
Not final approved (Appendix 1):
• Delete the progress note. This will delete the progress note and encounter at the same
time.
Final approved (unclaimed/claimed/paid/denied) (Appendix 2):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void the progress note.
Wrong client chart/Wrong date of encounter
If the wrong client chart or the wrong date of encounter was selected and the note is:
Not final approved (Appendix 1):
• Delete the progress note. This will delete the progress note and encounter at the same
time.
Final approved (unclaimed/claimed/paid/denied) (Appendix 2):
• Print a copy of the progress note so you may re-enter it in the correct client chart or on
the correct date of service.
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void the progress note.
• Be sure to enter your new note in the correct chart or on the correct date.
Duplicate progress note and encounter
If a second progress note was written for the same client for the same encounter and the note is:
Not final approved (Appendix 1):
• Delete the progress note. This will delete the progress note and encounter at the same
time.
Final approved (unclaimed/claimed/paid/denied) (Appendix 2):
• Contact your administrative support staff to check the billing status.
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• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void the progress note.
Change encounter to never billable activity
If never-billable activity (for example: clerical, payee service such as completing forms, filing CPS/APS
reports, leaving a voice message or faxing information) was provided and the note is:
Not final approved (Appendix 1):
• Delete the progress note. This will delete the progress note and encounter at the same
time.
• Re-enter the information as an informational progress note.
Final approved (unclaimed/claimed/paid/denied) (Appendix 2):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void the progress note.
• Re-enter the information as an informational progress note.
Change non-billable service code to an informational progress note
If a never-billable activity such as leaving a message or faxing a report is added to an individual progress
note with a non-billable service code (800 series), and the note is:
Not final approved (Appendix 1):
• Delete the progress note. This will delete the progress note and encounter at the same
time.
• Re-enter the information as an informational progress note.
Final approved (unclaimed) (Appendix 2- skip to step 4):
• Call the Optum Support Desk to void the progress note.
• Re-enter the information as an informational progress note.
The non-billable codes’ series will always be in their original state- never claimed or paid/denied.
Therefore, you will never submit a Void Service Request to the MHBU.
Wrong or insufficient information in the client narrative
If there is wrong or insufficient information in the client narrative (for example: incomplete
documentation, blank narratives, a different client’s full name is mentioned…) and the note is within 14
days of the DOS:
Not final approved (Appendix 1):
• Double click on the client narrative to open the narrative for editing. Complete any
needed edits.
Final approved (unclaimed) (Appendix 3) and within 14 days of the DOS:
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
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• Double click on the client narrative to open the narrative for editing. Complete any
needed edits before final approving.
Final approved (claimed/paid/denied) or more than 14 days from the DOS:
• Contact your administrative support staff to check the billing status.
• Contact QI Matters @ QIMatters.hhsa@sdcounty.ca.gov
Wrong billing indicator which affects billing (Lockouts, No-Show, DAS)
If the encounter has a wrong billing indicator which affects billing such as it was provided during a lock
out, client was a no show and it is not indicated, or service has a wrong diagnosis attached and the note
is:
Not final approved (Appendix 1):
• Double click on the encounter to open the encounter for editing. Change the
appropriate indicator and final approve the note as normal.
Final approved (unclaimed) (Appendix 4):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Void & Replicate the encounter. Change the appropriate indicator and final approve the
note as normal.
Final approved (claimed/paid/denied) (Appendix 5):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Remove the existing encounter.
• Re-enter the encounter using the correct indicator and final approve the note as
normal.
Wrong billing indicator which does NOT affects billing
If the encounter has a wrong billing indicator which does NOT affects billing such as, scheduled vs not
scheduled or language used and the note is:
Not final approved (Appendix 1):
• Double click on the encounter to open the encounter for editing. Change the
appropriate billing indicator(s) and final approve the note as normal.
Final approved (unclaimed) (Appendix 4):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Void & Replicate the encounter. Change the appropriate indicator and final approve the
note as normal.
Final approved (claimed/paid/denied) (Appendix 7):
• Enter an informational progress note, using the same date of encounter, to document
the error and the correct billing indicators.
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Wrong service code:
If the incorrect service code is selected and the note is:
Not final approved (Appendix 1):
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Double click on the encounter to open the encounter for editing. Input the correct
service code and save the encounter.
• If the new service code is also a planned encounter, re-link to the correct intervention
and objective in the “Related Client Plan.”
Final approved (unclaimed) (Appendix 6):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Void the existing encounter.
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.” If the new service code is also a planned
encounter, re-link to the correct intervention and objective in the “Related Client Plan.”
• Re-enter the entire encounter using the correct service code and save the encounter.
Final approve the note as normal.
Final approved (claimed/paid/denied) (Appendix 7):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know.
• Enter an informational progress note, using the same date of encounter, to document
the error and the correct service. Your administrative staff will have it fixed on the back
end with the MHBU.
Time data entry error:
This correction should not be used to fix unsubstantiated time. It should only be used to fix a data
entry error when, the amount of time entered on the encounter portion is greater than the time
documented within the content of the narrative and the note is:
Not final approved (Appendix 1):
• Double click on the encounter to open the encounter for editing. Edit the time data
error and final approve the note as normal.
Final approved (unclaimed) (Appendix 4):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Void & Replicate the encounter. Edit the time data error and final approve the note as
normal.
Final approved (claimed/paid/denied) (Appendix 7):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
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• Once the corrections are complete, the administrative staff will let you know.
• Enter an informational progress note, using the same date of encounter, to document
the error and the correct time. Your administrative staff will have it fixed on the back
end with the MHBU.
No active client plan OR progress note was final approved after 14 days:
If an encounter is documented and not covered by an active client plan (when a client plan is required),
or if the documentation date of the progress note is more than 14 CALENDAR days from the date of
encounter and the note is:
Not final approved (Appendix 1):
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Double click on the encounter to open the encounter for editing. Input the correct
service code (800 series- non-billable) and save the encounter. Remember service,
travel and documentation time, as well as billing indicators will reflect the actual
encounter that took place.
Final approved (unclaimed) (Appendix 6):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Void the existing encounter.
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Re-enter the entire encounter using the correct service code (800 series- non-billable)
and save the encounter. Remember service, travel and documentation time, as well as
billing indicators will reflect the actual encounter that took place. Final approve the
note as normal.
Final approved (claimed/paid/denied) (Appendix 5):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Remove the existing encounter.
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Re-enter the entire encounter using the correct service code (800 series- non-billable)
and save the encounter. Remember service, travel and documentation time, as well as
billing indicators will reflect the actual encounter that took place. Final approve the note
as normal.
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Change service code to a non-billable service code:
If a non-billable service code (i.e. solely payee services, solely transportation, academic, vocational,
recreation, or socialization) was provided and the note is:
Not final approved (Appendix 1):
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Double click on the encounter to open the encounter for editing. Input the correct
service code (800 series- non-billable) and save the encounter. Remember service,
travel and documentation time, as well as billing indicators will reflect the actual
encounter that took place.
Final approved (unclaimed) (Appendix 6):
• Contact your administrative support staff to check the billing status.
• Call the Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Void the existing encounter.
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Re-enter the entire encounter using the correct service code (800 series- non-billable)
and save the encounter. Remember service, travel and documentation time, as well as
billing indicators will reflect the actual encounter that took place. Final approve the note
as normal.
Final approved (claimed/paid/denied) (Appendix 5):
• Contact your administrative support staff to check the billing status.
• Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
• Once the corrections are complete, the administrative staff will let you know to call the
Optum Support Desk to void & replicate the progress note.
• Note the existing encounter information. It will need to be re-entered.
• Remove the existing encounter.
• If the existing service code was a planned encounter, unlink the intervention and
objective in the “Related Client Plan.”
• Re-enter the entire encounter using the correct service code (800 series- non-billable)
and save the encounter. Remember service, travel and documentation time, as well as
billing indicators will reflect the actual encounter that took place. Final approve the note
as normal.
Multiple Scenarios:
Lastly, if a progress note contains more than one of the above factors contact the Optum Support Desk
for assistance.
Clinical Appendix #1
1
Progress note is not final approved – the entire progress note and encounter can still be edited
or deleted if the note is not yet final approved.
To delete the entire progress note:
• Select “Delete” in the ribbon.
• A message will appear confirming the deletion. Click “Yes”; the progress note and encounter will
both be deleted.
To edit the client narrative:
• Double click on the “Client Narrative” to open the narrative for editing. The narrative box will
become yellow when you are able to type into it.
Clinical Appendix #1
2
• Complete any needed edits to the
client narrative and then select the
save icon.
To edit the encounter:
• Select the “Encounters” pane and double click on the encounter line that needs editing.
• Complete any needed
edits to the service code, service
time, travel time, documentation
time, assignment, billing
indicators, DAS, EBP and select
“Save.”**
**Reminder: If you are changing the service code of a planned encounter, you must unlink the
objectives/intervention in the “Related Client Plan” first, and save. If you are changing the service
code to a different planned encounter, after you have updated the encounter, you must re-link the
objective/interventions in the “Related Client Plan”, and save. See Appendix 5, page 2 for more
detail.
Clinical Appendix #2
1
Void the progress note and the encounter
- it is possible that the entire note and encounter need
to be voided. This can occur in the following situations:
Encounter did not occur
Wrong client chart
Wrong date of encounter
Duplicate progress note and encounter
The encounter should have been entered as NEVER billable activity (I.E. informational
note)
The non-billable service code should have been entered as an informational note
• If you have a non-billable service code that needs to be an informational note, skip to
step 4. Non-billable 800 series codes are never claimed.
1. Contact your administrative support staff to check the status of the billing.
2. Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period if the encounter has been
claimed, paid or denied.
3. Once the admin’s process is complete, the administrative staff will let you know.
4. Call the Optum Support Desk to void the progress note.
5. If necessary, enter the information in an informational progress note, or re-enter the
information into the correct client chart or on the correct date.
Clinical Appendix #3
1
Edit the progress note and keep the encounter (NOT CLAIMED)- it is possible that only the client
narrative needs edits and the encounter is fine. This can occur in the following situations:
Wrong or insufficient information in the client narrative
1. Contact your administrative support staff to check the status of the billing.
• STOP: If there is wrong of insufficient information in the client narrative and the
encounter is post 14 days, claimed, paid or denied,
contact QIMatters.HHSA@sdcounty.ca.gov
.
2. Once the admin’s process is complete, the administrative staff will let you know.
3. Call the Optum Support Desk to void and replicate the progress note.
4. Double click on the “Client Narratives” to open the narrative for editing. The narrative
box will become yellow when you are able to type into it.
5. Complete any needed edits to the
client narrative and then select the
save icon.
6. Complete your edits the same day and final approve the note as normal. Co-Signatures
will be needed again, if applicable.
Clinical Appendix #4
1
Keep the progress note and edit the encounter (NOT CLAIMED)
- it is possible that only the
encounter needs edits and the client narrative is fine. This can occur in the following situations:
Wrong billing indicator which affects billing (Lockouts, No-Show, DAS)- when the
encounter is not claimed
Wrong billing indicator which does NOT affect billing- when the encounter is not
claimed
Time data entry error- when the encounter is not claimed
1. Contact your administrative support staff to check the status of the billing.
• If the encounter is claimed, paid or denied, please refer to the matrix for the
applicable appendix.
2. Call the Optum Support Desk to void and replicate the progress note.
3. Select the “Encounters” pane. Right click on the encounter, and select “Void and
Replicate Encounter.”
• This option will only be enabled after the note has been voided and replicated by the
Optum Support Desk.
4. This will void the existing encounter and allow you to make a minor change. A
confirmation box will appear; select “Yes.”
5.
Complete any needed edits to the encounter and then select “Save.”
6. Complete your edits the same day and final approve the note as normal. Co-Signatures
will be needed again, if applicable.
Clinical Appendix #5
1
Keep the progress note, but remove and reenter the encounter (CLAIMED/PAID/DENIED)
- it is
possible that the encounter needs to be reentered and the client narrative is fine. Removing the
encounter will remove it from the progress note, but not void it from the system. Once any
billing activity has taken place, the encounter can no longer be voided. The only option is to
remove it. This can occur in the following situations:
Wrong billing indicator which affects billing (Lockouts, No-Show, DAS) - when the
encounter is claimed/ paid/ or denied
No active client plan- when the encounter claimed/ paid/ or denied
Progress note was final approved after 14 days- when the encounter is claimed/ paid/ or
denied
Change the service code to a non-billable service code- when the encounter is claimed/
paid/ or denied
1. Contact your administrative support staff to check the status of the billing.
2. Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period.
3. Once the admin’s process is complete, the administrative staff will let you know.
4. Call the Optum Support Desk to void and replicate the progress note.
5. Note the existing encounter information. It will need to be re-entered.
6. Select the “Encounters” pane. Right click on the encounter, and select “Remove
Encounter.”
• This option will only be enabled after the note has been voided and replicated by the
Optum Support Desk.
7. This will remove the existing encounter from the progress note. This will allow you to
enter in a new encounter with the correct information. A confirmation box will appear;
select “Yes.”
Clinical Appendix #5
2
8. If you are changing the service code of a planned encounter, you must unlink the
objectives/intervention in the “Related Client Plan.” Select the edit icon.
9. Unselect the intervention by clicking on the green check box.
10. If you are changing the service code to a different planned encounter, you must re-link
the objectives/intervention in the “Related Client Plan,” and save. If the service code is
being changed to an unplanned service code, including the 800 series codes, simply
select the save icon.
• If this step is not completed, the encounter will be considered ‘Unplanned,’ even
if the service code is listed as an intervention in the client plan.
Clinical Appendix #5
3
11. Select the “Encounters” pane. Double click on the red line to reenter the encounter with
the correct billing indicators and/or non-billable service code, as applicable. If
applicable, ensure the 800 series non-billable service code is billed with the correct
billing indicators and actual service, travel and documentation time.
12. Complete your encounter entry the same day and final approve the note as normal. Co-
Signatures will be needed again, if applicable.
Clinical Appendix #6
1
Keep the progress note, but void and reenter the encounter (NOT CLAIMED)
- it is possible that the
encounter needs to be reentered and the client narrative is fine. Voiding the encounter will
remove it from the system. Encounters are only able to be voided up until billing activity has
taken place. This can occur in the following situations:
Wrong service code- when the encounter is not claimed
No active client plan- when the encounter not claimed
Progress note was final approved after 14 days- when the encounter is not claimed
Change the service code to a non-billable service code- when the encounter is not
claimed
1. Contact your administrative support staff to check the status of the billing.
2. Once the admin’s process is complete, the administrative staff will let you know.
3. Call the Optum Support Desk to void and replicate the progress note.
4. Note the existing encounter information. It will need to be re-entered.
5. Select the “Encounters” pane. Right click on the encounter, and select “Void Encounter.”
• This option will only be enabled after the note has been voided and replicated by the
Optum Support Desk.
6. This will void the existing encounter from the progress note. This will allow you to enter
in a new encounter with the correct information. A confirmation box will appear; select
“Yes.”
7. If you are changing the service code of a planned encounter, you must unlink the
objectives/intervention in the “Related Client Plan.” Select the edit icon.
Clinical Appendix #6
2
8. Unselect the intervention by clicking on the green check box.
9. If you are changing the service code to a different planned encounter, you must re-link
the objectives/intervention in the “Related Client Plan,” and save. If the service code is
being changed to an unplanned service code, including the 800 series codes, simply
select the save icon.
• If this step is not completed, the encounter will be considered ‘Unplanned,’ even
if the service code is listed as an intervention in the client plan.
Clinical Appendix #6
3
10. Select the “Encounters” pane. Double click on the red line to reenter the encounter with
the correct billing indicators and/or non-billable service code, as applicable. If
applicable, ensure the 800 series non-billable service code is billed with the correct
billing indicators and actual service, travel and documentation time.
11. Complete your encounter entry the same day and final approve the note as normal. Co-
Signatures will be needed again, if applicable.
Clinical Appendix #7
1
Complete an informational note
- it is possible that something is incorrect in the client narrative or
within the encounter, but it does not require a correction to the original note. Some of the
billing corrections are made on the back end between your administrative staff and the MHBU.
This can occur in the following situations:
Wrong billing indicator which does NOT affect billing- when the encounter is claimed/
paid/ denied
Wrong service code- when the encounter is claimed/ paid/ denied
Time data entry error- when the encounter is claimed/ paid/ denied
1. Contact your administrative support staff to check the status of the billing.
2. Your administrative support staff may have to work through their process to take care
of the entered encounter. There will be a waiting period.
3. Once the admin’s process is complete, the administrative staff will let you know.
4. Enter an informational progress note using the “Progress Note Correction” note.
5. Complete your entry the same day and final approve the note as normal.
