This section will introduce the users to the steps required to code a visit and finalize the note. The user will be guided through the coding of a Preventive Exam (well visit) with steps to easily finalize the visit. This section is specific to the provider workflow.
- Select the Coding tab .
- Verify the Visit Type is correct for the visit (Established or New Patient).
- Click Use Suggested CPT button.
- If there are Abnormal findings, place a check mark in the Abnormal Findings box.
- To add additional CPT codes, follow the steps below.
- Locate the Category and select the procedure code by double clicking - or - click the Lookup CPT button.
- Click the Summary tab to review the note.
|Note: The Patient Exit Note will be created when the note is finalized. The following steps are optional.|
- Click the Finalize button to lock the note in it's current state.
- The Confirm dialog box displays.
- Click the OK button or Cancel button if not prepared to finalize the note.
- Diagnosis code(s) for the visit are listed in the Diagnosis section of the window.
- To add or modify ICD-10 codes, follow the steps below.
- Begin typing the name or code of the diagnosis code.
- Press the Enter key.
- The ICD-10 window display.
- Click to select a code.
- If the code is not found, click the Full Search button.
- The ICD-10 Code table displays.
- If the ICD-10 Code is not visible use the radio buttons on the window to expand the search.