Patient Encounter: Services and Procedure Coding

Version 20.12

About Patient Encounter: Services and Procedure Coding Tab

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button > Coding
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click > Open encounter > Coding

The Services and Procedure Coding window establishes the correct CPT codes for the encounter using the E/M guidelines for Time or MDM. For additional information on how Time and MDM are calculated in OP, we encourage you to visit the 2021 E/M Coding & Documentation Changes Resource Center.

Patient Encounter: Services and Procedure Coding Tab Map

Number
SectionDescription
1
Coding buttonThe Coding button opens the Services and Procedures 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
Visit Status and Room drop-downsThe Visit Status and Room drop-down menus allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Appointment windows.
5
Coding tabsThe Coding tabs focus on the CPT codes for the patient encounter:
  • Diagnostic/Procedure Codes: The Diagnostic/Procedure Codes tab is used to review and select the Procedure CPT code for the Patient Encounter based on Tracked Time or MDM.  The calculation of each code is based on the 2021 E/M coding guidelines.
  • Coding Decision Support(Legacy): The Coding Decision Support Legacy tab is the coding calculator for a patient encounter (sick visit) based on the 2020 CMS coding guidelines.
  • Time Details: The Time Details tab is read-only and displays the specific amount of time spent by the Rendering Provider in each of the time-tracked areas in OP on the date of the visit. The information is grouped by category according to the Visit Status preference settings made by the practice.
6
E/M, Categories, and Templates radio buttonsThe E/M, Categories, and Templates radio buttons toggle the CPT grid between CPT code categories and template categories.
7
Tracked TimeThe Tracked Time section displays the time the provider has spent on the patient encounter including pre-visit preparation, intra-visit work, and post-visit work (from 12:01 AM-11:59 PM).
  • The Learn More button will take you to the tracked time content on the Help Center.
  • The Attested Time drop-down allows you to override the total time calculated by OP.
  • The Add Suggested Code button applies the CPT code that was determined based upon OP's tracked-time code calculation.  Clicking this button applies the CPT code to the sick visit.
8
MDMThe MDM section displays 3 elements of Medical Decision: Problems Addressed, Data Reviewed, and Risk of Complications.
  • The Learn More button will take you to the MDM content on the Help Center.
  • The Add Suggested Code button applies the CPT code that was determined based upon OP's MDM calculation.  Clicking this button applies the CPT code to the sick visit.
  • The Details button displays the information used to calculate the level of MDM based on the documentation of the three elements of MDM.
9
Visit TypeThe Visit Type radio buttons display the proper CPT code based upon the type of visit (Established visit, New Patient Visit).
10Diagnostic/Procedure Codes Worksheet function buttonsThe Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient encounter.
11
Add CPT Code button

The Add CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to search and add a CPT code.
12
Billing Status drop-down
The Billing Status drop-down menu allows the user to select the appropriate Billing Status of the visit. This selection updates the Tracking and Appointment windows.
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.
Version 20.11

About Patient Encounter: Services and Procedure Coding Tab

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button > Coding
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click > Open encounter > Coding

The Services and Procedure Coding window establishes the correct CPT codes for the encounter using the E/M guidelines for Time or MDM. For additional information on how Time and MDM are calculated in OP, we encourage you to visit the 2021 E/M Coding & Documentation Changes Resource Center.

Patient Encounter: Services and Procedure Coding Tab Map

Number
SectionDescription
1
Coding buttonThe Coding button opens the Services and Procedures 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
Visit Status and Room drop-downsThe Visit Status and Room drop-down menus allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Appointment windows.
5
Coding tabsThe Coding tabs focus on the CPT codes for the patient encounter:
  • Diagnostic/Procedure Codes:  The Diagnostic/Procedure Codes tab is used to review and select the Procedure CPT code for the Patient Encounter based on Tracked Time or MDM.  The calculation of each code is based on the 2021 E/M coding guidelines.
  • Coding Decision Support(Legacy):  The Coding Decision Support Legacy tab is the coding calculator for a patient encounter (sick visit) based on the 2020 CMS coding guidelines.
6
E/M, Categories, and Templates radio buttonsThe E/M, Categories, and Templates radio buttons toggle the CPT grid between CPT code categories and template categories.
7
Tracked TimeThe Tracked Time section displays the time the provider has spent on the patient encounter including pre-visit preparation, intra-visit work, and post-visit work (from 12:01 AM-11:59 PM).
  • The Learn More button will take you to the tracked time content on the Help Center.
  • The Attested Time drop-down allows you to override the total time calculated by OP.
  • The Add Suggested Code button applies the CPT code that was determined based upon OP's tracked-time code calculation.  Clicking this button applies the CPT code to the sick visit.
8
MDMThe MDM section displays 3 elements of Medical Decision: Problems Addressed, Data Reviewed, and Risk of Complications.
  • The Learn More button will take you to the MDM content on the Help Center.
  • The Add Suggested Code button applies the CPT code that was determined based upon OP's MDM calculation.  Clicking this button applies the CPT code to the sick visit.
  • The Details button displays the information used to calculate the level of MDM based on the documentation of the three elements of MDM.
9
Visit TypeThe Visit Type radio buttons display the proper CPT code based upon the type of visit (Established visit, New Patient Visit).
10Diagnostic/Procedure Codes Worksheet function buttonsThe Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient encounter.
11
Add CPT Code button

The Add CPT code button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to search and add a CPT code.
12
Billing Status drop-down
The Billing Status drop-down menu allows the user to select the appropriate Billing Status of the visit. This selection updates the Tracking and Appointment windows.
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.