| OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients. |
Version 14.19
 This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Well Visit: Coding
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits > New or Open Note button > Coding
Path: Clinical, Practice Management, or Billing tab > Schedule button > Calendar or Tracking radio button > Right-click > Open well visit > Coding
The Coding window suggests the correct CPT codes for the Well Visit based on the patient's age and status with the Practice (new patient vs. established patient). You may also select your own office visit and/or procedure codes.
Well Visit: Coding Map
Number | Section | Description |
1 | Coding Button | The Coding button accesses the Coding window in the patient's Well Visit Note. |
2 | Well Visit Function buttons | The function buttons delete an entire Well Visit Note, edit a Well Visit Note, or save a Well Visit Note. |
| 3 | Lookup CPT button | The Lookup CPT button opens the CPT-4: Physicals Current Procedural Terminology, Fourth Edition window to search, add, delete, or modify a private or local CPT code. |
| 4 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox marks the Well Visit Note as unfinished. |
5 | Categories/Templates radio buttons | The Categories/Templates radio buttons toggle the CPT grid between CPT code categories and template categories. |
6 | Visit Status and Room drop-downs | The 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 Calendar views. |
7 | CPT Code Category/Template panel | The 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 Type radio buttons | The Visit Type radio buttons display 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 Suggested button | The 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 Well Visit Note. The Code appears in the lower panel of the Diagnostic/Procedure Codes tab. |
10 | Diagnosis/Procedure Codes Worksheet | The Diagnosis/Procedure Codes worksheet enters procedure notes and applies diagnosis codes to the selected CPT code for the Well Visit. 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 | 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 Calendar views. |
12 | Diagnostic/Procedure Codes Worksheet function buttons | The Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the Well Visit. |
Version 14.10
About Preventive Exam: Coding Tab
Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > Coding tab
Path: Smart Toolbar > Schedule Button > Well Visit tab > Edit button > Coding tab
The Preventive Exam window charts a patient well-visit exam. The Preventive Exam window helps to code and complete a preventive encounter visit. The preventive exam 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 well visit using the OP Coding Decision Support. You may also select your own office visit and/or procedure codes.
Preventive Exam: Coding Tab Map
Number | Section | Description |
1 | Well Visit Note Editor tab | The Well Visit Note Editor documents the patient preventive exam. The Well Visit Note Editor contains the following tabs:
|
2 | Categories/Templates radio buttons | The Categories/Templates radio buttons toggle the CPT grid between CPT code categories and template categories. |
3 | Care Plans tab | The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule. |
4 | Prior Well Visits tab | The Prior Well Visits tab lists the previous preventive exam notes. |
5 | Templates tab | The Templates tab lists the templates that are created, edited, and reviewed in the Well Visit Template Editor. Templates are pre-written scenarios you can use in a well visit 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. |
6 | Lookup CPT button | The 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 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox will mark a well visit as unfinished. |
8 | CPT Code Category/Template panel | The 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). |
9 | Use Suggested | The 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 | Visit Type | The 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). |
11 | Diagnosis/Procedure Codes Worksheet | The 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. |
12 | 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. |
