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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.

Patient Encounter: Services and Procedure Coding

Version 14.19

About Patient Encounter: Services and Procedure Coding Tab

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Coding
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Coding
Path: Billing tab > Patient Chart button > Encounter > New or Open Note button > Coding

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Services and Procedure Coding window establishes the correct CPT codes for the encounter using the OP Coding Decision Support, or allows you to select your own office visit code and/or procedure codes.

Patient Encounter: Services and Procedure Coding Tab Map

Number
SectionDescription
1
Coding buttonThe Coding button opens the Coding window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
Coding tabsThe Coding tabs focus on the CPT codes for the patient encounter:
  • Diagnostic/Procedure Codes tab:  The Diagnostic/Procedure Codes tab is used to look up and select the Diagnostic/Procedure CPT codes for the Patient Encounter.  The CPT Code Category/Template panel (upper panel) contains the CPT code catalog where you can search for and select the desired CPT code.  Once the CPT code is selected, the code appears in the Diagnostic/Procedure Codes worksheet (lower panel).  Once the CPT code is in the lower panel, you can enter diagnostic codes to connect to the CPT code in the lower panel.
  • Coding Decision Support tab:  The Coding Decision Support tab is the coding calculator for a patient encounter (sick visit).   The calculator uses the type of visit, history documentation, exam documentation, complexity of medical decision making, and time to determine the CPT code.  The entire visit length in minutes should also be registered here. The Documentation number will change based upon the selections made in the coding calculator.  When complete, click the Apply button to apply the suggested code to the visit.  The code will appear in the lower pane of the Diagnostic/Procedure Codes tab.
  • Coding Statistics tab: The Coding Statistics tab graphs the CPT codes used based upon the provider and date range radio buttons selections.
5
Categories/Templates radio buttonsThe Categories/Templates radio buttons toggle the CPT grid between CPT code categories and template categories.
6
Lookup CPT buttonThe Lookup CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to look up, add, delete, or modify a private or local CPT code.
7
CPT Code Category/Template panelThe CPT Code Category/Template panel displays the CPT code list based upon Categories or Templates radio button selections.  CPT codes for the visit can be selected in this panel and used in the Diagnostic/Procedure Codes worksheet (the lower panel).  
8
Visit TypeThe Visit Type radio buttons displays the proper CPT code (that was determined in the Coding Decision Support tab) based upon the type of visit (Established visit, New Patient Visit, Consultation).
9
Use SuggestedThe Use Suggested button applies the CPT code that was determined based upon the selection made in the Coding Decision Support tab and the Visit Type set in the Diagnostic/Procedure Codes tab.  Clicking this button applies the CPT code to the sick visit.  The Code appears in the lower panel of the Diagnostic/Procedure Codes tab.
10
Diagnosis/Procedure Codes WorksheetThe Diagnosis/Procedure Codes worksheet enters procedure notes and applies diagnosis codes to the selected CPT code for the patient encounter. The CPT codes entered on this tab are passed to the Electronic Superbill. In cases where the same CPT code is entered multiple times, only one instance of the code will be passed to the superbill.
11
Diagnostic/Procedure Codes Worksheet function buttons
The Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient encounter.
Version 14.10

About Patient Encounter: Coding Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Coding tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Coding tab

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Coding tab establishes the correct CPT codes for the encounter using the OP Coding Decision Support, or allows you to select your own office visit code and/or procedure codes.

Patient Encounter: Coding Tab Map

Number
SectionDescription
1
Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:

2
Categories/Templates radio buttonsThe Categories/Templates radio buttons toggle the CPT grid between CPT code categories and template categories.
3
Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
4
Visit DateThe Visit date field indicates the date that the patient encounter occurred.
5
Prior Notes tabThe Prior Notes tab lists the previous encounter notes and messages.
6
Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.

7
Coding tabsThe Coding tabs focus on the CPT codes for the patient encoutner:
  • Diagnostic/Procedure Codes tab:  The Diagnostic/Procedure Codes tab is used to look up and select the Diagnostic/Procedure CPT codes for the Patient Encounter.  The CPT Code Category/Template panel (upper panel) contains the CPT code catalog where you can search for and select the desired CPT code.  Once the CPT code is selected, the code appears in the Diagnostic/Procedure Codes worksheet (lower panel).  Once the CPT code is in the lower panel, you can enter diagnostic codes to connect to the CPT code in the lower panel.
  • Coding Decision Support tab:  The Coding Decision Support tab is the coding calculator for a patient encounter (sick visit).   The calculator uses the type of visit, history documentation, exam documentation, complexity of medical decision making, and time to determine the CPT code.  The entire visit length in minutes should also be registered here. The Documentation number will change based upon the selections made in the coding calculator.  When complete, click the Apply button to apply the suggested code to the visit.  The code will appear in the lower pane of the Diagnostic/Procedure Codes tab.
  • Coding Statistics tab: The Coding Statistics tab graphs the CPT codes used based upon the provider and date range radio buttons selections.
8
Lookup CPT buttonThe Lookup CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to look up, add, delete, or modify a private or local CPT code.
9
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
10
CPT Code Category/Template panelThe CPT Code Category/Template panel displays the CPT code list based upon Categories or Templates radio button selections.  CPT codes for the visit can be selected in this panel and used in the Diagnostic/Procedure Codes worksheet (the lower panel).  
11
Visit TypeThe Visit Type radio buttons displays the proper CPT code (that was determined in the Coding Decision Support tab) based upon the type of visit (Established visit, New Patient Visit, Consultation).
12
Use SuggestedThe Use Suggested button applies the CPT code that was determined based upon the selection made in the Coding Decision Support tab and the Visit Type set in the Diagnostic/Procedure Codes tab.  Clicking this button applies the CPT code to the sick visit.  The Code appears in the lower panel of the Diagnostic/Procedure Codes tab.
13
Diagnosis/Procedure Codes WorksheetThe Diagnosis/Procedure Codes worksheet enters procedure notes and applies diagnosis codes to the selected CPT code for the patient encounter. The CPT codes entered on this tab are passed to the Electronic Superbill. In cases where the same CPT code is entered multiple times, only one instance of the code will be passed to the superbill.
14
Diagnostic/Procedure Codes Worksheet function buttonsThe Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient encounter.