Code and Finalize an Encounter Visit (Sick Visit)

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 an encounter (sick visit) with steps to easily finalize the visit.  This section is specific to the provider workflow.

  1. Select the Assess/Plan button.

  1. Diagnosis code(s) for the visit are listed in the Diagnosis section of the window.
  2. To add or modify ICD-9 or ICD-10 codes, follow the steps below.
  • Begin typing the name or code of the diagnosis code.
  • Press the Enter key. The ICD-9/ICD-10 window display
  • Click to select a code.
  • If the code is not found, select the Master list and or the Complete radial button 
  1. #* The ICD-9/ICD-10 Code table displays.
  • If the ICD-9/ICD-10 Code is not visible use the radio buttons on the window to expand the search.

  1. Click on the Coding tab and Verify the Visit Type is correct for the visit.  OP will always default to Established, if its a New patient visit or Consult, you will need to manually change this.
  2. Click Use Suggested CPT Code, or select the code you feel is appropriate from the list above.

  1. To add additional CPT codes, follow the steps below.
  • Click the Plus icon.
  • The Superbill: Pending Charges for Procedures window displays.

  1. Locate the Category and select the procedure code - or - click the Lookup CPT button.
  2. Click the Summary button to review the 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
  • Click the Rebuild Summary button.
  1. Click the Finalize button to lock the note in it's current state.
  2. Finalize confirm window display.

  1. Click the OK button - or - Cancel button if not prepared to finalize the note.

NOTE: If there wasn't a template available and you created this patient note from scratch you may save it as a template by clicking on . Once you click on Save As Template you will name the template, choose the category that the template should sit in, and then choose the sections that should be part of the template and save it by clicking on the OK button.