Procedure Entry Screen-Top Section

• Fields in Left Column
• Fields in Right Column
• Post-Op Care Message
• Setting up Post-Op Care Parameters
• ICD-10 Coding Tool
• Data Definitions for ICD-10 Codes

Prompt	Response	Req	Len
Name	Displays the Account # and Patient Name as a hyperlink. You can click the link to access the patient's account from within this function. This opens the Change Patient Data function and all screens accessed from the hyperlink display ***from Procedure Entry*** at the top of the screen. This allows you to review and change any or all patient information while in the Procedure Entry Function, if necessary. If you do not have security access for Change Patient Data, the link takes you to Review Patient Information instead.
Date	Type the Accounting date or click the calendar icon to select a date. Future dates are not permitted. If you are using Batch numbers, this field is the date stored for the Batch and you cannot change it. You can create a batch for a future date when creating a batch, but you cannot post procedures to the batch number until the accounting date becomes current. If you are not using a batch, the default date is the current system date, which may be changed if necessary. If you change the date, this field defaults with that same date when you access the next patient account, for as long as you stay in the Procedure Entry Function or until you change the date again. The accounting date determines the aging of the procedures and which month's productivity statistics will be affected. As you are posting procedures you can also indicate the actual dates of service, which could be different from the accounting date. This is helpful if, for example, a procedure does not get entered until a later date (such as hospital visits). You could use the date it was entered as the accounting date, which would determine the aging for the procedure.		10
DOB (Age) Sex	Displays the patient's date of birth, calculated age, and sex.
Batch	If you entered a batch number in the procedure entry lead-in screen, the batch number you entered is a hyperlink you can click to access the Batch Inquiry screen for that batch. The Batch Inquiry screen displays ***from Procedure Entry*** at the top of the screen.
Case	If these charges are applicable to a certain case, type the Case code you want or select a code from the Case list. You can click Add a Case in the Action Column if you need to add a new case. The case defaults if you post using Superbill Numbers and a Case was selected for the appointment. If the patient has any active cases, the word 'Case' is colored blue to alert you. If you select a case and click the Authorization Attachment, only the authorizations assigned to that case display. If you leave the Case field blank and click the Authorization Attachment, only the authorizations not assigned to a case display. If you select a case, the diagnosis codes default based on the following criteria in the order listed: If Default DX's from Patient's Last Visit is selected in the Procedure Entry Integration function: If the Case has not been previously posted with any procedures, the Primary Diagnosis for the case defaults. If the Primary Diagnosis field for the case is blank, no diagnosis code(s) default. If the Case has been previously posted with procedures, the diagnosis codes for the previously posted procedures for the case default. Also, if a # is stored in the Primary Diagnosis field for the case, the diagnosis codes from the previously posted procedures for the case default. If Default DX's from Patient's Last Visit is not selected in the Procedure Entry Integration function (regardless of whether the Default Diagnosis field in the Patient Name & Address screen contains a '#' or not): If a Case is selected that contains a Primary Diagnosis, that diagnosis code defaults. Also, if a # is stored in the Primary Diagnosis field for the case, the diagnosis codes from the previously posted procedures for the case default. If the Primary Diagnosis field for the Case is blank, no diagnosis code(s) default.		5
Per Dr	This field indicates which doctor actually performed the procedure(s). Type the code you want or select a code from the list. The following criteria is used to determine the default doctor: If you are posting using superbill numbers, defaults to the appointment doctor code. If you do not post using superbill numbers, defaults to the patient's Responsible Doctor code. If you select a case: Defaults to the case doctor code. If you go back and remove the Case entirely, the Per Dr field does not update and you must manually change the Per Dr and Ins Dr if necessary. If there is no doctor tied to the case, the Per Dr code is not changed.		6
Ins Dr	This field indicates which doctor will be submitted on the insurance claim. Type the code you want or select a code from the list. The following criteria is used to determine the default doctor: If you are posting using superbill numbers, defaults to the Default Ins Dr tied to the appointment doctor code. If there is no Default Ins Dr for the appointment doctor code, it defaults to the appointment doctor code. If you do not post using superbill numbers, defaults to the Default Ins Dr tied to the Per Dr code. If there is no Default Ins Dr for the Per Dr, it defaults to the Per Dr. If you select a case: Defaults to the Default Ins Dr tied to the case doctor code. If there is no Default Ins Dr tied to the case doctor code, it defaults to the Case Doctor code. If there is no doctor tied to the Case, the Ins Dr code is not changed.		6
Sup Dr	This field defaults with the Default Sup Doctor stored in the Doctor Code Table for the Per Dr. Click the magnifying glass to add or change the doctor in this field. Click the X icon to the right of the field to remove a doctor from this field. This field pulls from a combination of the Doctor Code Table and the Referral Source Table. This is indicated in the Source column in the Table Search window. Note that not all insurance carriers require this field and some may reject claims if this information is included on electronic claims. Be aware of the carrier's requirements before including this information on the claim.		6
Loc	This field indicates where the services were performed. The default displayed is either the default location contained in the Patient Name record or, if you are posting from superbill numbers, the location the patient was scheduled at. To change the location, type the code you want or select a code from the list. If you enter a location code that has one of the following inpatient Place of Service Codes tied to it in Maintain Location Codes, when you click Save after entering charges, a new screen opens so you can enter the Admit Date and Discharge Date. (21 = Inpatient Hospital, 31 = Skilled Nursing Facility, 51 = Inpatient Psychiatric, 61 = Comprehensive Inpatient Rehab, 62 = Comprehensive Outpatient Rehab)		6
Superbill #	If your practice has selected to post from superbill numbers, this number defaults from the previous screen. The superbill number must be numeric, if entered, and may not contain leading zeros. This unique superbill number may not be used again. This entry is used to track superbill numbers.		25
Department #	This field automatically defaults to the department code entered in the doctor code table for the Performing Doctor but you can change it as needed. Type the department code you want or select from the Department list.		3
Claim Hold	You can specify when you want to hold the filing of transactions until a future date. When you type a date in this field to hold the claim from filing: The transaction immediately moves to the insurance balance and is marked with the 'H' insurance flag. That way you can easily see when reviewing Transaction History which transactions/claims have a hold on them. Any charges on hold still appear in the Insurance Balance portion of the patient statement, but the charges are not marked as billed to the insurance. Transactions on hold do not enter the insurance collections process. Any transactions that are on hold appear on the Insurance Never Filed report. The transactions are included in the Create Insurance File function when the claim hold date is reached.		10
Reason	Type the reason for the claim hold.		50

Prompt	Response	Req	Len
Ins	Displays the CGM webVERIFY Status icons (if your practice subscribes to CGM webVERIFY), Eligibility History icon, primary and secondary insurance carrier codes and the accept assignment flag for each carrier. If the patient has more than one primary or secondary policy, the code of the first primary policy is the one displayed. CGM webVERIFY Eligibility Status icons: (CGM webVERIFY clients only) Verification Failed - Red Verification Passed - Green Verification Outdated - Grey Verification Partial - Yellow Never Verified - Clear - denotes a policy that has never been verified. If you point to the icon, a ScreenTip will state either, 'Never Verified' or 'Never Verified. Carrier does not contain a CGM webVERIFY Identifier.' You can click the Status icon to check eligibility for the carrier The status icon reflects the status of the specific result being viewed, not the current eligibility status for the policy. You can click the Status icon to re-check eligibility for the insurance carrier. CGM webVERIFY Eligibility History icon: You can click the icon to display the eligibility results history. Note: In order to verify eligibility from within the Procedure Entry Function, you must have security access to Change Patient Data. In order to view eligibility history from within the Procedure Entry Function, you must have security access to Change Patient Data or Review Patient Data.		5
Balance	Informational only. Displays the current account balance (including insurance and patient balances).		5
Billing Group	This field automatically defaults to the Billing Group stored for the patient on the Billing Information screen. To change the billing group for this encounter, type the code or click the magnifying glass to search for the code you want.		8
Last Visit	Informational only. Displays the Last Visit date and Brief Description of the first procedure code posted for that date of service.		10
Comment	Informational only. Displays any internal comment contained in the Billing screen for the patient. This field is limited to display only forty characters because any comments greater than that can cause display issues in the screen.		40
Diagnosis	When you access the function, if the Allow Entry of ICD-9 Codes check box is selected in the Procedure Entry Integration function, separate tabs for the ICD-9 and ICD-10 codes display. You can toggle between the two tabs as needed. If the Allow Entry of ICD-9 Codes check box is not selected, you can only enter ICD-10 codes. The diagnosis search field is the top field in the diagnosis section. You can search by code, partial code, keyword, and multiple keywords can also be chained together (for example, cat bitten). When you start typing in the field, the diagnosis results auto-fill in a window beneath the diagnosis search field. You can use the arrow keys to move up and down within the results list, or you can use the pointer to select a code in the list. After selecting the code you want, press Enter or TAB to add the code to the Encounter screen. The magnifying glass icon accesses the ICD-10 Coding Tool so you can search for the diagnosis code(s) you want. You can quickly add, change, or delete diagnosis codes and update their associated pointers with the Delete and Sync icons located to the right of the magnifying glass icon. The Delete icon deletes all currently selected diagnosis codes and their associated pointers on each procedure line item. The Sync icon syncs the diagnosis pointers for all the procedure line items to match the order of the first four selected diagnosis codes. You can enter up to 12 diagnosis codes for the encounter and link up to four diagnosis codes to an individual procedure code. All diagnosis codes entered here are referred to as Encounter DX's. Each code can be reordered by selecting a new order from the drop-down list next to the code. You can remove a code from the list by clicking the drop-down list next to the code and clicking the X icon. There are specific logical steps that determine if any code(s) should be defaulted. As soon as one of the conditions is satisfied, the process is completed and the code(s) display; otherwise the process continues until it is determined which code(s) to default. The code stored in the Default Diagnosis field in the Patient Name and Address screen defaults. If the Default Diagnosis field in the Patient Name and Address screen contains a '#', the diagnosis codes from the previously posted procedures default. If Default DX's from Patient's Last Visit is selected in the Procedure Entry Integration function: If a Case is not selected: If the patient account has not had procedures posted, it defaults the Default Diagnosis from the Patient Name & Address screen. If a '#' is stored in the Default Diagnosis field, the diagnosis codes for the previously posted procedures default. If the patient account has been previously posted with procedures, the diagnosis codes for the previously posted procedures default. If a Case is selected: If the Case has not been previously posted with any procedures, the Primary Diagnosis for the case defaults. If the Primary Diagnosis field for the case is blank, no diagnosis code(s) default. If the Case has been previously posted with procedures, the diagnosis codes for the previously posted procedures for the case default. Also, if a '#' is stored in the Primary Diagnosis field for the case, the diagnosis codes from the previously posted procedures for the case default. If Default DX's from Patient's Last Visit is not selected in the Procedure Entry Integration function (regardless of whether the Default Diagnosis field in the Patient Name & Address screen contains a '#' or not): If a Case is not selected: If the patient account has not had procedures posted, it defaults the Default Diagnosis from the Patient Name & Address screen. If a '#' is stored here, the diagnosis codes for the previously posted procedures default. If the patient account has been previously posted with procedures, it defaults the Default Diagnosis from the Patient Name & Address screen. If a '#' is stored in the Default Diagnosis field, the diagnosis codes for the previously posted procedures default. If a Case is selected: If the Case contains a Primary Diagnosis, that diagnosis code defaults. If a '#' is stored in the Primary Diagnosis field for the case, the diagnosis codes from the previously posted procedures for the case default. If the Primary Diagnosis field for the Case is blank, no diagnosis code(s) default.		10
Ref Dr	This field indicates which doctor referred the patient for the procedure(s). Type the code you want or click the magnifying glass to search the table and select a doctor. The following criteria is used to determine the default doctor: It initially defaults to the Referral Source stored in the Patient Name and Address Information screen. If you select a case: If there is a referral source tied to that case, the Ref Dr field updates with that referral source. If there is no referral source tied to the case that you selected, the Ref Dr field changes to 0-No Referral Source. If you select Case 0 Not Applicable (0), the Ref Dr field defaults to the Referral Source stored in the Patient Name and Address Information screen. The referral source tied to the service script always takes precedence over both the referral source stored in the Patient Name and Address Information and the referral source tied to the case, because that is what is required on the claim. Therefore: If there is a service script tied to the charges, and if there is a referral source tied to the service script, the Ref Dr field defaults with the referral source tied to the service script. If there is a service script and a case tied to the charges, the Ref Dr field defaults with the referral source tied to the service script. If you remove the service script from the charges, the Ref Dr field defaults as described in the first four bullet points.		6
Svc Script	If your practice uses Service Scripts, type the Service Script date you want to tie to the encounter or click the '?' icon to list the available service scripts entered for the patient and select one. If you post using superbill numbers and if there is a Service Script tied to the appointment, that service script date defaults.		10
Date of Ill/Inj	This field is used to store the date of illness or injury when the insurance carrier only requires a date be provided on the insurance claim. When the insurance carrier requires a date and the additional case information fields, you need to tie a Case to the encounter. If the service date is prior to the Date of Ill/Inj, a warning message displays when you click Save. The Date of Ill/Inj must occur on or before at least one of the service dates in the encounter. Note: If you receive the warning message and the Date of Ill/Inj was automatically populated from a Case record: Click the QuickLink icon or the Patient Name hyperlink in the upper-left corner of the Procedure Entry screen to access Change Patient Data. Edit the Date of Ill, Inj, Lmp field in the Case record. Return to Procedure Entry. Re-select the Case to refresh the date in the Date of Ill/Inj field. Save the encounter.		10
Ins Dr Taxonomy	The taxonomy code stored for the Ins Dr defaults in the field. To change the Ins Dr Taxonomy, select from the list. This field defaults with the Primary taxonomy code stored in the Taxonomy Code field in Maintain Doctor Codes for the Ins Dr selected here. If there are multiple taxonomy codes stored for the doctor, they are available from the drop-down list. If you change the Ins Dr, this field updates accordingly. If the Individual check box is selected in the Doctor Code Table for the Ins Dr, this taxonomy code is not sent on claims. If the Individual check box is not selected, the taxonomy code is sent on electronic claims.		20

• Maintain Post-Op Days (Tables > Procedure Code Table > Post-Op Days Table)
• Maintain Procedure Codes (Tables > Procedure Code Table)
• CGM webPRACTICE Integration Options (System > Database Maintenance Menu > Integrations)
• Maintain Type of Service Codes (Tables > Type of Service Table)

1. The number of days stored in the Maintain Post-Op Days function.
2. The number of days in the Post-Op Days field in Maintain Procedure Codes.
3. The number of days in the Number of Days for Post-Op field in the CGM webPRACTICE Integration Options.
4. If the Surgery Type of Service Code is selected for any Type of Service codes and no value is stored in the Number of Days for Post-Op field, 90 days is the default.