Version 20.16
 This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Patient Encounter: (Services and Procedure) Coding
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button > Coding
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click > Open encounter > Coding
The Services and Procedure Coding window suggests the correct CPT codes for the encounter using the E/M guidelines for Time or MDM. For additional information on how Time and MDM are calculated in OP, For additional information on how Time and MDM are calculated in OP, see E/M Coding in OP.
Patient Encounter: Services and Procedure Coding Tab Map
Number | Section | Description |
1 | Coding button | The Coding button accesses the Services and Procedures Coding window in the patient's Encounter Note. |
2 | Encounter Function buttons | The Function buttons delete an entire Encounter Note, edit an Encounter Note, or save an Encounter Note. |
3 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox marks an Encounter as unfinished. |
4 | Visit Status and Room drop-downs | The Visit Status and Room drop-downs allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Calendar Schedule views. |
5 | Coding tabs | The Coding tabs focus on the CPT codes for the patient Encounter:
|
6 | E/M, Categories, and Templates radio buttons | The E/M, Categories, and Templates radio buttons toggle the CPT grid between CPT code categories and template categories. |
7 | Tracked Time | The Tracked Time section displays the time the provider has spent on the patient Encounter including pre-visit preparation, intra-visit work, and post-visit work (from 12:01 AM-11:59 PM).
|
8 | MDM | The MDM section displays 3 elements of Medical Decision: Problems Addressed, Data Reviewed, and Risk of Complications.
|
9 | Visit Type | The Visit Type radio buttons display the proper CPT code based upon the type of visit (Established visit, New Patient Visit). |
| 10 | Diagnostic/Procedure Codes Worksheet function buttons | The Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient Encounter. |
11 | Add CPT Code button | The Add CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to search and add a CPT code. |
12 | Billing Status drop-down | The Billing Status drop-down allows the user to select the appropriate Billing Status of the visit. This selection updates the Tracking and Calendar Schedule views. |
13 | Diagnosis/Procedure Codes Worksheet | The Diagnosis/Procedure Codes worksheet enters procedure notes and applies diagnosis codes to the selected CPT code for the patient Encounter. The CPT codes entered on this tab are passed to the Electronic Superbill. In cases where the same CPT code is entered multiple times, only one instance of the code will be passed to the superbill. |
Version 20.15
This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Patient Encounter: (Services and Procedure) Coding
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button > Coding
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click > Open encounter > Coding
The Services and Procedure Coding window suggests the correct CPT codes for the encounter using the E/M guidelines for Time or MDM. For additional information on how Time and MDM are calculated in OP, For additional information on how Time and MDM are calculated in OP, see E/M Coding in OP.
Patient Encounter: Services and Procedure Coding Tab Map
Number | Section | Description |
1 | Coding button | The Coding button accesses the Services and Procedures Coding window in the patient's Encounter Note. |
2 | Encounter Function buttons | The Function buttons delete an entire Encounter Note, edit an Encounter Note, or save an Encounter Note. |
3 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox marks an Encounter as unfinished. |
4 | Visit Status and Room drop-downs | The Visit Status and Room drop-downs allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Calendar Schedule views. |
5 | Coding tabs | The Coding tabs focus on the CPT codes for the patient Encounter:
|
6 | E/M, Categories, and Templates radio buttons | The E/M, Categories, and Templates radio buttons toggle the CPT grid between CPT code categories and template categories. |
7 | Tracked Time | The Tracked Time section displays the time the provider has spent on the patient Encounter including pre-visit preparation, intra-visit work, and post-visit work (from 12:01 AM-11:59 PM).
|
8 | MDM | The MDM section displays 3 elements of Medical Decision: Problems Addressed, Data Reviewed, and Risk of Complications.
|
9 | Visit Type | The Visit Type radio buttons display the proper CPT code based upon the type of visit (Established visit, New Patient Visit). |
| 10 | Diagnostic/Procedure Codes Worksheet function buttons | The Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient Encounter. |
11 | Add CPT Code button | The Add CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to search and add a CPT code. |
12 | Billing Status drop-down | The Billing Status drop-down allows the user to select the appropriate Billing Status of the visit. This selection updates the Tracking and Calendar Schedule views. |
13 | Diagnosis/Procedure Codes Worksheet | The Diagnosis/Procedure Codes worksheet enters procedure notes and applies diagnosis codes to the selected CPT code for the patient Encounter. The CPT codes entered on this tab are passed to the Electronic Superbill. In cases where the same CPT code is entered multiple times, only one instance of the code will be passed to the superbill. |
