Code and Finalize a Preventive Exam

Version 14.8


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. 

  1. Select the Coding tab .
  2. Verify the Visit Type is correct for the visit (Established or New Patient).
  3. Click Use Suggested CPT button.
  4. If there are Abnormal findings, place a check mark in the Abnormal Findings box.

  1. 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 Patient Exit Note tab.
  • Click the Rebuild Summary button to create the Patient Exit Note.
  • Click on the Note button to print if needed.

  1. Click the Finalize button to lock the note in it's current state.
  2. The Confirm dialog box displays.
  3. Click the OK button or Cancel button if not prepared to finalize the note. 

  1. Diagnosis code(s) for the visit are listed in the Diagnosis section of the window.
  2. 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.