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Code and Finalize a Patient Visit Note

Version 20.7
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits or Encounters > New or Open Note button
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click appointment > Open Well Visit or Open Encounter

Overview

Below are the steps a Provider will take to code and finalize a patient's visit.

Assessment: Review/Add Diagnosis Code(s)

  1. Navigate to the Visit Note by following one of the paths above.
  2. Click Assessment in the Window Navigation panel.
  3. Review the diagnosis code(s) for the Visit in the Diagnoses section of the window, and add or modify if necessary. To add or modify ICD-10 codes:
  1. Enter the name or description in the ICD-10 Description field or the ICD-10 code in the ICD-10 field.
  2. Press Enter on your keyboard or click the Search button. The ICD window displays with the practice's Frequently Used list.
  3. Choose the code, and click the Select button. If the code was not displayed in the Frequently Used list, click the Full Search button and select the Complete and Master radio buttons to expand the search and make your selection.
  4. Repeat the above steps for any additional diagnosis codes.

NoteSelect the checkbox in the Add PL column if the diagnosis should be added to the patient's problem list. Click the Yes or Yes + Details to confirm.

  • If you chose Yes, you are required to complete the entry in the Problem List at a later time. 
  • If you chose Yes + Details, the Problem List window opens to complete any additional information.

Coding: Code the Visit

  1. From within the Visit Note, click Coding in the Window Navigation panel.
  2. Click Coding in the Window Navigation panel. 
  3. Verify the Visit Type is correct. The default is Estab. If coding for a new patient visit or consultation, select the appropriate radio button.
  4. Click the Use Suggested button to apply the suggested E/M code.
  5. (Well Visits only) If there were abnormal findings, select the Abnormal Findings checkbox.
  6. Review the CPT Codes in the lower section of the Coding window.

Note: CPT codes associated with the applied template will show in the lower section of the window. Additional CPT codes can be added and will show in the visit note, but duplicated CPT codes will not pass to the electronic superbill. When appropriate, the units of a CPT Code can be modified on this window. If duplicated, CPT codes must be billed on separate claim lines, and your practice will need to develop a process for notifying your billers.

  1. Add additional CPT codes, if necessary.
  1. Click a Category button.
  2. Double-click a CPT code to select it. If the CPT code was not found in the Category, click the Lookup CPT button and select the Complete and Master radio buttons to expand the search and make your selection.
  3. Repeat the above steps for additional CPT codes.

Note: After all appropriate ICD-10 and CPT codes have been added to the visit, assign the diagnosis codes to the corresponding procedure (CPT) codes by clicking in the DX1, DX2 etc. fields and selecting the appropriate DX for each CPT.

  1. (Optional) Select Ready to Bill from the Billing Status from the drop-down to indicate the visit is ready to be billed. This status is displayed on the Tracking Schedule.

Summary: Finalize the Note

  1. From within the Visit Note, click Summary in the Window Navigation panel.
  2. Review the Note.
  3. (Optional) Create a Patient Exit Note to provide to the parent.
  1. Click the Patient Exit Note tab.
  2. Click the Rebuild Summary button.
  3. Click the Print Note button to print.

  1. (Optional) Complete the Note reviewed by field. If the practice or state requires a percentage of Notes charted by mid-levels or medical students to be reviewed, and the reviewer is visible on a note, click the drop-down arrow and select the reviewer.
  2. Click the Finalize button. The Confirmation dialog box is displayed.
  3. Click the OK button to finalize or click the Cancel button if you are not prepared to finalize.

NoteIn the Staff Provider directory window, if the co-signature required checkbox is selected for the user, then the Note is not locked down when the user finalizes the note. Notes can then be edited by the supervising provider. If the co-signature required is not selected in the Staff/Provider Directory window when the user finalizes the Note, then the Note will not appear on the supervisor's list to review.