OP Coding Decision Support
This article contains a collection of printable Quick Reference Guides.
The Importance of Finalizing Notes in a Timely Fashion
The Importance of Finalizing Notes in a Timely Fashion Sue Kressly, MD, FAAP Medical Director, OP Providers often ask me why it’s important to finalize notes in the EHR or what the industry standard is. There are four main reasons to fin...
Vital Signs and Growth Measurements
In this section you will find the steps to document the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements.
How Charges Get to the Superbill
There are several triggers that generate charges for a patient when documenting a visit.
Using the HCPCS Level 2 Code 3008F for Pay for Performance (P4P)
Version 14.19 Overview Many users question how they can get more room on their well visit claims to report all of the pay for performance (P4P) items that the payer wants them to report. Consider the use of HCPCS level 2 code 3008F, "BMI as...
This article will show you how to layer templates. Additional templates can be applied when working from the the CC/HPI/ROS, Detailed Exam Tab. or the Assess/Plan Tab.
Invalidating a Finalized Encounter or Well Visit Note (Providers Only)
Version 14.19 Invalidating a Finalized Note It may be necessary to invalidate an encounter or well visit note in the event that it was erroneously entered. To invalidate a finalized note: Click the Patient Chart button and search...
Save a Template When Charting
While working on a sick or well visit for a patient, you may realize how beneficial it may be to save this visit as a template. With the following steps you can quickly build up your template library
Charting a Sick Visit with a Well Visit
While conducting a Well Visit, the provider may find that he/she needs to incorporate a Sick encounter note for the same day.
Note Marked as Incomplete
Version 14.19 Overview There may be instances when a provider needs a visual reminder that an encounter or well visit note is incomplete. Prior to saving a note, an indicator can be set as this visual reminder to flag the note as incomplete.&nbs...
Cosign a Note
Version 14.19 Overview If it is required that mid-level providers need a provider to cosign notes, then the steps below will complete this workflow. It is important to note that for any well or encounter visit which requires a cosignature, the m...
Adding and Sorting DX Codes for Claims
Version 14.19 Overview OP, adhering to CMS guidelines, allows up to 12 diagnosis codes per claim with a max of 4 per CPT code. Previously, only the diagnosis codes that were attached to a CPT code would be transmitted on a claim. With the curren...
Viewing Prior Notes While Charting a Visit
Overview There are several ways in which prior Well and Encounter notes can be viewed during the charting of a visit. These methods include: Using the Prior Notes button Using Event Chronology Using the Tabbed Interface option Leaving the Char...
Print a Patient Exit Note
Overview While the Patient Exit Note can be printed from both finalized and unfinalized Encounters and Well Visit notes, the steps to do so are slightly different. Print the Patient Exit Note from a Finalized Note Navigate to and select the Enco...
Converting from Paper Charts to Electronic Charts
Overview As the practice moves from paper charts to an electronic health record in OP, it is important to first determine what content needs to be populated into the electronic health record. Some points to consider before the process of data...