We are currently updating the OP Help Center content for the release of OP 14.19 or "OP 19". OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Preventive Exam: Coding

Version 14.19

About Preventive Exam: Coding

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

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 window 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 Map

Number
SectionDescription
1
Coding ButtonThe Coding button opens the Coding window in the patient's preventive exam note.
2
Well Visit Function buttonsThe function buttons delete an entire well visit note, edit a well visit note, or save an well visit note.
3
Complete List button

The Complete List button 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.

4
Prior Notes button
The Prior Notes button opens a lists the previous preventive exam notes.
5
Categories/Templates radio buttons
The Categories/Templates radio buttons toggle the CPT grid between CPT code categories and template categories.
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
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
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).
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
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.
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.
12
Flag as Incomplete checkbox
The Flag as Incomplete checkbox will mark an encounter as unfinished.
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
SectionDescription
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 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
Prior Well Visits tabThe 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 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
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark a well visit as unfinished.
8
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).  
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
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).
11
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.
12
Diagnostic/Procedure Codes Worksheet function buttonsThe Diagnostic/Procedure Codes Worksheet function buttons delete, edit, and save the CPT code entries for the patient encounter.