Code and Finalize a Preventive Exam

Version 14.8

Overview

Path: Smart Toolbar > Chart button > Well Visits tab > Start New Note or Open Note button

This section will guide the user through the steps required to code a Preventive Visit and finalize the note. This section is specific to the Provider's workflow. 

  1. Select the Assess/Plan tab.

  1. Review the diagnosis code(s) for the visit listed in the Diagnoses section at the top of the window.
  2. Modify the codes when necessary.  To add or modify ICD-10 codes, follow the steps below:
  1. Click the ICD-10 field that says 'Click here to add a new diagnosis code'.
  2. Begin typing a description of the diagnosis code in the ICD-10 Description column or enter the code itself in the ICD-10 column.
  3. Press the Enter key. The ICD-10 window displays.
  4. Select a code and click the Post Edit button.
    or
    If the code is not found:
  1. click the Full Search button.
  2. Select the Master radio button to open the Master list and/or select the Complete radio button. The ICD-10 Code table displays.
  3. Highlight the code. 
  4. Click the Select button.
  5. Click the Post Edit button.
  1. Click the Coding tab and verify the Visit Type is correct.  OP will default to Established. If this is a New patient visit, select the correct radio button.
  2. Click the Use Suggested button.
  3. If there were abnormal findings, click the Abnormal Findings (ICD-10 only) checkbox.

  1. To add additional CPT codes, follow the steps below.
  1. Click a Category button.
  2. Double-click a CPT code from the panel, repeat as necessary.

or

  1. Click the Lookup CPT button.
  2. Enter the CPT or Description.
  3. Click the Search button. The search will default to the Frequently used list of codes, but you may have to search the Complete List. To do so, click the 'Complete list' radio button.
  4. Double-click to add, repeat as necessary.

Note: After all appropriate ICD-10 and CPT codes have been added to the visit, the user will want to assign the diagnosis codes to the corresponding procedure (CPT) codes.
  1. Click the Summary tab to review the visit note.


   Note: The Patient Exit Note will be created when the note is finalized. The following steps are optional.
  1. Click the Patient Exit Note tab.
  2. Click the Rebuild Summary button to create the Patient Exit Note.
  3. Click on the Print Note button to print.


Note: The Chart reviewed by field is optional. If the practice or state requires a percentage of notes charted by mid-levels or medical students to be reviewed, click the drop-down arrow and select the reviewer. The staff selected as the reviewer will display on the finalized note. It is implied a complete chart review was done for the patient not just today's note.
  1. Click the Finalize button to lock the note in its current state.The Confirm dialog box displays.
Note: In the Staff Provider directory window, if the co-signature required checkbox is selected for the user, then the note is not locked down when this 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.
  1. Click the OK button if you are prepared to finalize the note.  
       or
       Click the Cancel button if you are not prepared to finalize the note.