The Visit tab displays a variety of visit-specific information and allows the user to update visit and accident information.
Its child tabs allow the user to manage notes, diagnoses, procedures, physicians, and surgical HCPCS information.
To update visit information, follow these steps:
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.
To add a note, follow these steps:
The information populates the list.
You can only delete a note prior to saving it. Click the Delete button. The note is removed.
Although notes cannot be deleted once they have been saved, strikethrough lines can be applied to out-of-date notes.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:
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.
To add a charge, follow these steps:
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.
Credits can be applied as long as they have the same charge date as the original charge. To add a credit, follow these steps:
To update a charge/credit, follow these steps:
Entries can be deleted from the list if they have not been saved. To delete charge/credit entries, follow these steps:
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.
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:
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:
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:
To delete a diagnosis, follow these steps:
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:
To delete a procedure, follow these steps:
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:
To update a surgical HCPCS code, follow these steps:
To delete a surgical HCPCS code, follow these steps:
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:
To delete a physician, follow these steps:
The Addl. Info tab is used to collect facility-defined information that is not captured elsewhere in the system. This information is captured using a variety of data types (text, numbers, dollars, dates, times, drop-down menus, etc.) and is unique to a location. The Patient column indicates whether the data entered is stored at the patient (Yes) or visit (No) level.
To add information to a user-defined field, follow these steps:
The information displays in the Value column in the list.
To update a user defined field, follow these steps:
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.