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We are currently updating the OP Help Center content for the release of OP 20. OP 20 (official version 20.0.x) is the certified, 2015 Edition, version of the Office Practicum software. This is displayed in your software (Help tab > About) and in the Help Center tab labeled Version 20.0. We appreciate your patience as we continue to update all of our content.

Code and Finalize a Preventive Exam

Version 14.19

Overview

Path: Clinical, Billing, or Practice Management tab > Patient Chart button > Well Visits > 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. 

Assessment

  1. Select Assessment.

  1. Review the diagnosis code(s) for the visit listed.
Select 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.
  1. Modify the codes when necessary.  To add or modify ICD-10 codes, follow the steps below:
  1. Begin typing the name in the ICD-10 Description field or code in the ICD-10 field
  2. Press the Enter key. The ICD window will display with the practice frequently used list.
  3. Repeat the above steps for any additional diagnosis codes.

If the code is not found:

  1. Click the Full Search button. The ICD Code table displays.
  2. Click the radio button Complete and Master to expand the search.
  3. Highlight the code in the list and click the Select button.

Coding the Visit

  1. Click Coding and verify the Visit Type is correct. OP will default to Established. If this is a New patient visit, select the correct radio button.

  1. Click the Use Suggested button.

  1. If there were abnormal findings, click the Abnormal Findings (ICD-10 only) checkbox.
  2. To add additional CPT codes, follow the steps below.
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 here. 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. Click a Category button.
  2. Double-click a CPT code from the panel.
  3. Repeat the above steps for additional CPT codes.repeat as necessary.

If the CPT code is not found in a Category follow the steps below.

  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.
  4. If the code is not found, click the Full Search button. Click the radio button Complete and Master to expand the search
  5. Double-click on the CPT code to add, 
  6. Repeat the above steps for additional CPT codes.
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.

Finalize a Note

  1. Click Summary 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 Note 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.


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 Finalize button to lock the note in its current state. The Confirm dialog box displays.

  1. Click OK if you are prepared to finalize the note or click Cancel if you are not prepared to finalize the note.
Version 14.10

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.
Select 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.
  1. 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.
Note: CPT codes associated with the applied template will show in the lower pane 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 here. 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. 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.