Collections Visit Tab

The Visit tab displays a variety of read-only information regarding the patient, visit, and billing. It also displays group information, if needed.

Its child tabs show all financial activity (charges, payments, and adjustments) applied to the selected billing event. The tabs also allow the user to manage diagnosis, procedure, surgical HCPCS, and physicians for the visit.

Notes

The Notes tab lists all user and system-generated notes that are associated with the visit. Note information includes the date, user, code, and narrative. Notes can be sorted by clicking on the column headers. Coded or free-form notes can be added in the tab.

Click the System Notes checkbox to view only system-generated notes.

Add Notes

To add a note, follow these steps:

1. Click the Add button . A row is added to the Notes list with the current date, user adding the note, and the application area (Collections, Billing, Registration, etc.) populated and the Visit Note Information fields enabled.

2. Enter note information using one the following options:
   • Coded note – Enter a note code in the first field or a note description in the autocomplete field (clicking a suggested description to select it).

• • Free-form note – Enter free-form note text into the Narrative field.

The information populates the list.

You can only delete a note prior to saving it. Click the Delete  button. The note is removed.

3. Click Save.

Strikethrough a Note

Although notes cannot be deleted once they have been saved, strikethrough lines can be applied to out-of-date notes. The Strike action is located to the right of the Narrative field for saved notes. The strikethrough option allows notes to be designated as no longer used, helping the user determine which information is current on the medical record. Strikethrough lines can be removed. To strike a note, follow these steps:

1. Click Strike in the Action column to the right of the note narrative. A strikethrough line displays over the note’s fields.

2. Click Save.
3. To remove the strikethrough line, click Un-Strike.

Charges

The Charges child tab under the Visit parent tab displays all charges and credits that have been applied to the billing event and allows the user to add charges/credits. The list includes the charge date, charge code, revenue ID, quantity, amount, and other charge detail.

Clicking on a charge populates the detail section below, which allows the user to update certain charge information, including the charge date, physician, diagnosis, HCPCS code and modifiers, and NDC code.

Credits are displayed with a minus quantity and amount.

Add a Charge

To add a charge, follow these steps:

1. Click the Add button . A row is added to the list and the entry fields are enabled.
2. Charge Date – Enter the date for the charge/credit. The field defaults to the current date.
3. SSPN – Enter an alphanumeric SSPN.

4. Charge Cd – Enter a charge code in the first field or a charge description in the autocomplete field (clicking a suggested description to select it).
5. Hcpcs – Enter a HCPCS code in the first field or a HCPCS description in the autocomplete field (clicking a suggested description to select it).
6. Modifiers – Enter any HCPCS modifier codes. The first modifier field is enabled when an HCPCS code is entered. The second field is enabled when a modifier is entered in the first field, and so on. The modifier codes clarify the services billed while not changing the procedure code. They add more information, such as the anatomical site, to the HCPCS code. In addition, they help to eliminate the appearance of duplicate billing and unbundling.
7. Physician – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).  A physician must be entered here in order to be listed on the 1500 claim bill.
8. Diagnosis – Click the Diagnosis button to rank diagnoses already associated with the visit.
9. Start Date/End Date – The fields are disabled if the charge code does not charge by time. Enter effective dates and times for a charge code that is set up to charge by time. An amount of time is assigned to a charge code (for example, 1 unit = 15 minutes).
10. Do Not Bill – Check to keep the charge from being placed on a claim. This requires configuration with a Billing option.
11. Quantity – Enter the quantity of this charge code. The Total Amount field updates.

Note: For time-based charges, the system rounds up to the nearest time increment to calculate the price. For example, if the charge has 15-minute increments and the charge time was 16 minutes, the quantity will be 2.

12. Price – Displays the price associated with the charge code. Depending on a setting in Charge Maintenance, this field may be available for override.
13. Total Amount – Displays the total charge (quantity x price). Depending on a Global Registry setting, this field may be available for override.
14. NDC – Enter an NDC code in the first field or an NDC description in the autocomplete field (clicking a suggested description to select it).
15. Meas – Click the dropdown to change the NDC’s measure code. This defines the unit of measure (units, grams, etc.) used for a dose of the drug.
16. Mult – Click the dropdown to change the NDC’s quantity multiplier. This defines the quantity of the measure (units, grams, etc.) used for a dose of the drug.

17. Click Save.

Add a Credit

Credits can be applied as long as they have the same charge date as the original charge. To add a credit, follow these steps:

1. Click on a charge entry in the list to select it.

2. Click the Credit button . The credit row is added to the list with the quantity and amount displayed as negative numbers, and the fields are enabled below the list.

3. Click Save. The credit will be listed with negative numbers and no Credit button .

Update Charge/Credit Entries

To update a charge/credit, follow these steps:

1. Click on a charge/credit in the list to select it. The detail displays below.

2. The following fields can be updated:
   • Charge Date – Click the field to enter the date directly or click to select a date from a calendar.
   • SSPN – Enter an alphanumeric SSPN.
   • HCPCS – Enter a HCPCS code in the first field or a HCPCS description in the autocomplete field (clicking a suggested description to select it).
   • Mod – Enter any HCPCS modifier codes. The first modifier field is enabled when an HCPCS code is entered. The second field is enabled when a modifier is entered in the first field, and so on. The modifier codes clarify the services billed while not changing the procedure code. They add more information, such as the anatomical site, to the HCPCS code. In addition, they help to eliminate the appearance of duplicate billing and unbundling.
   • Physician – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).
   • Diagnosis – Enter a diagnosis code in the first field or a diagnosis description in the autocomplete field (clicking a suggested description to select it).
   • Start Date/End Date – The fields are disabled if the charge code does not charge by time. Enter effective dates and times for a charge code that is set up to charge by time. An amount of time is assigned to a charge code (for example, 1 unit = 15 minutes).Do Not Bill. Check to keep the charge from being placed on a claim. This requires configuration with a Billing option.
   • Quantity – Enter the quantity of this charge code. The Total Amount field updates.
   • NDC – Enter an NDC code in the first field or an NDC description in the autocomplete field (clicking a suggested description to select it).
   • Meas – Click the drop-down menu to change the NDC’s measure code. This defines the unit of measure (units, grams, etc.) used for a dose of the drug.
   • Mult – Click the drop-down menu to change the NDC’s quantity multiplier. This defines the quantity of the measure (units, grams, etc.) used for a dose of the drug.

3. Click Save.

Delete Charge/Credit Entries

Entries can be deleted from the list if they have not been saved. To delete charge/credit entries, follow these steps:

1. Click on a charge/credit entry in the list to select it.

2. Click the Delete button . The charge/credit is deleted from the list.
3. Click Save.

Charge Diagnosis

The Charge Diagnosis option is used to associate a diagnosis or multiple diagnoses with a charge and rank them. The user can assign up to four diagnoses that have already been associated with the visit. Those diagnoses can be ranked, which determines their order on the 1500 and 837p.

Note: The 1500 billing option for the diagnosis pointer field (FL24E) must be set to 8.

Associate Diagnoses

The Charge Diagnosis window displays all associated diagnoses. Up to four diagnoses can be ranked, but they cannot have the same rank. To associate and rank diagnoses, follow these steps:

1. Click on the arrows or enter the rank directly into the Rank field for a diagnosis.

2. Click Save. The Rank 1 diagnosis displays in the Diagnosis field on the Charges tab.

Payments/Adjustments

The Payments/Adjustments tab displays all payments and adjustments that have been applied to the billing event. Clicking on a payment/adjustment in the list populates the detail section below and allows the user to update the billing period.

To update a payment or adjustment, follow these steps:

1. Click on a payment/adjustment to select it. The transaction’s detail displays below the list, and the Period dropdown menu is enabled.

2. Click the Period dropdown to select a different billing event. The payment/adjustment will be applied to the selected billing event.
3. Click Save.

Diagnosis

The Diagnosis tab is used to add or delete diagnoses (admitting, final, or secondary) for the visit. The diagnoses indicate what a patient is being treated for and can work in conjunction with Medical Necessity Checking to verify the necessity of certain procedures.

While multiple diagnoses can be added, only one admitting and one final diagnosis are allowed on the visit. Secondary diagnoses have no limit.

Diagnoses can be added to the visit record by using existing diagnosis codes or by entering free-form text. Only admitting and secondary diagnoses can be added via free-form text.

To add a diagnosis, follow these steps:

1. Click the Add  button. A row is added to the list, and the Type dropdown menu defaults to:
   • Admitting – If there are no other diagnosis codes associated with the visit. This is the diagnosis/major complaint when the patient was admitted.
   • Final – If there is an admitting diagnosis code associated with the visit. This is the official diagnosis (if determined to be different from the admitting diagnosis), as determined by the facility’s personnel, and the issue treated.
   • Secondary – If there are admitting and final diagnoses codes associated with the visit. This is a diagnosis that is recorded for tracking but may not be related to the principal diagnosis.

2. Type – Click the drop-down and select a diagnosis type, if needed.
3. POA – Click the drop-down and select an option to identify if the diagnosis was present on admission.
4. Enter the diagnosis by one of the following methods:
   • Diagnosis. Enter a diagnosis code in the first field or a diagnosis description in the autocomplete field (clicking a suggested description to select it).

• • Freeform. Enter free-form text into the field.

5. Click Save.

Delete Diagnoses

To delete a diagnosis, follow these steps:

1. Click on a diagnosis in the list to select it.
2. Click the Delete button . The diagnosis is deleted from the list.
3. Click Save.

Procedure

The Procedure tab is used to add or delete procedure codes for a visit. Procedures can be added as principal or secondary, but a visit can only have one principal procedure. Procedures cannot be updated.

To add a procedure, follow these steps:

1. Click the Add  button. A row is added to the list, and the Procedure Information fields below are enabled. The Type dropdown menu will default to Principal if there are no procedures on the visit and Secondary if there is already a Principal type.

2. Type – Click the dropdown and select a procedure type (principal or secondary).
3. Procedure – Enter a procedure code in the first field or a procedure description in the autocomplete field (clicking a suggested description to select it).
4. Date – This date defaults to the admit date. Click the field to enter the date directly or click to select a date from a calendar.

5. Click Save.

Delete Procedures

To delete a procedure, follow these steps:

1. Click on a procedure in the list to select it.
2. Click the Delete button . The procedure is deleted from the list.
3. Click Save.

Surgical Hcpcs

The Surgical Hcpcs tab is used to add or delete HCPCS codes related to surgical procedures. The date, revenue ID, and HCPCS code and modifiers can be saved for the surgical procedure.

To add a surgical HCPCS code, follow these steps:

1. Click the Add  button. A row is added to the list, and the Surgical Hcpcs Information fields below are enabled.

2. Date – Click the field to enter the date directly or click to select a date from a calendar.
3. Rev Id – Enter a revenue ID in the first field or a revenue ID description in the autocomplete field (clicking a suggested description to select it).
4. HCPCS – Enter a HCPCS code in the first field or a HCPCS description in the autocomplete field (clicking a suggested description to select it).
5. Modifiers – Enter any HCPCS modifier codes. The first field is enabled when an HCPCS code is entered above. The second field is enabled after an entry in the first field.

6. Click Save.

Update Surgical HCPCS Codes

To update a surgical HCPCS code, follow these steps:

1. Click on a code in the list to select it.
2. Update the date, revenue ID, HCPCS code, or modifiers.
3. Click Save.

Delete Surgical HCPCS Codes

To delete a surgical HCPCS code, follow these steps:

1. Click on a code in the list to select it.
2. Click the Delete button . The code is deleted from the list.
3. Click Save.

Physicians

The Physician tab is used to add or delete physicians (admitting, attending, etc.) to the visit. This provides a history of physicians who have treated the patient during the visit. While multiple physicians can be added, only one Admitting and one Attending physician are allowed on the visit.

To add a physician, follow these steps:

1. Click the Add  button. A row is added to the list, and the Physician Information fields below are enabled.

2. Type – Click the dropdown menu and select a Physician Type (attending, consulting, ordering, etc.).
3. Phys Id – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).

4. Click Save.

Delete Physicians

To delete a physician, follow these steps:

1. Click on a physician in the list to select it.
2. Click the Delete button . The physician is deleted from the list.
3. Click Save.

Room/Bed

The Room/Bed tab displays information regarding admissions, transfers, discharges, etc. for a visit. The read-only tab lists the effective date along with the description and create date for the activity.