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Editing Procedures  

Procedures are usually entered in the Chart module using the Enter Treatment tab. To edit a procedure, double click it in the Account module, the Treatment Plan module, or the Chart module.

To edit, delete, or set procedures complete, the logged on user must have the correct security Permissions. Once procedures have been attached to a Claim, a note will show at the bottom of the Procedure Info window warning you that certain fields should not be changed. These fields will be grayed out. To make changes anyways, click Edit Anyway.

Dates:
Date Entry: Initially this date is the day the procedure was entered. The date is updated when the procedure is set complete. It cannot be manually edited.
Date TP: The day the procedure was added to the treatment plan.
Date: Date of the procedure. Enter start and end times, or click Now to add the current time. The Final field will automatically calculate the total minutes.

Procedure/Description: Click Change to select a different procedure code from the Procedure Code List. This will also update the Amount field. If the new code's treatment area is different, you will not be allowed to change it due to a 'treatment area mismatch'. For example. you cannot change a filling procedure to a prophy procedure, because the treatment area for a filling is Tooth and for a prophy is Mouth. Once you attach a Claim to an incorrect procedure, it is more complex. See Fixing Incorrect Procedures on an Insurance Claim.

Multiple instances of same procedure: Sometimes you need to add the same procedure multiple times, such as when administering many units of anesthesia. In these cases, add the procedure once, then change the Unit Quantity on the Procedure - Medical tab to account for the additional units. For example, to add 45 minutes of D9221 (deep sedation/general anesthesia - each additional 15 minutes), add the procedure once, then enter 3 as the Unit Quantity.  

For guidelines on entering procedures that involve multiple appointments, see Dental Lab Cases.

Tooth/Surface: Options for tooth number and surfaces are different depending on the Procedure Code's Treatment Area.
Tooth: A single tooth number. This is required if treatment area is set to tooth.
Surfaces: B/F, V, M, O/I, D, L. Enter or click a button to select. Click again to clear. This is required if treatment area is set to surface.
Quadrant: UR = upper right, UL = upper left, LR = lower right, LL = lower left
Sextant: 1 - 6 in United States. 03 - 08 in Canada.
Arch: U = upper, L = lower
Tooth Range: 1 - 32. Click and drag to select a range of teeth.

To use international tooth numbers, or for information on valid tooth numbers or supernumerary teeth, see Chart Module Preferences, Tooth Nomenclature.

Amount: The billable fee of the procedure based on the fee schedule. Enter default fees in the Procedure Code list. The fee only shows if the logged on user has the Show Procedure Fee Permission.

Hide Graphics: Check this box to hide this procedure on the Graphical Tooth Chart.

Clinic: If using Clinics, the clinic associated with this procedure.

Provider: The Provider associated with the procedure. If using Clinics and providers are restricted to clinics in Security, only providers available for the selected clinic are options.

Diagnosis: You can select one diagnosis per procedure. If a procedure requires more than one diagnosis (for instance: cracked tooth, IP, Apical perio) add them as notes. Diagnoses do not affect the graphical tooth chart. Customize options in Definitions, Diagnosis. To see diagnoses separately from the proposed treatment, see the comments regarding the Condition (Cn) Status.

Priority: Used to prioritize treatment in the Treatment Plan module. Options can be customized in Definitions, Treat' Plan Priorities.

Prosthesis Replacement: Only visible if the Procedure Code has been setup as “Is Prothesis.” This information is sent in e-claims only and is required before sending electronically. If Replacement is selected, an Original Date is required. To flag the date as estimated, check the Is Estimated box. The flag is only supported in 5010 e-claims. For 4010 e-claims, there is no place to send this flag, but it may be useful for documentation. Enter this information for printed claims on the Edit Claim, General tab.

E-claim Note: A place for short notes that pertain to this procedure. Limited to 80 characters. It should be used rarely and is only sent in E-Claims; it will not print on paper claims. The note is procedure level, not a claim level. To enter a Claim Note, see Claims.

Procedure Status: The procedure status can be one of the following:

  • Treatment Planned (TP): For work that is recommended, but not complete yet.
  • Complete (C): The work is done and will show in the patient's Account.
  • Existing-Current Prov (EC): Procedure was done in your practice before you started using Open Dental.
  • Existing-Other Prov (EO): Procedure was done by another provider, either before the patient came to your practice, or because they were referred out for treatment.
  • Referred Out (R): Procedure the patient needs, but that will be done at another office. Once the work has been completed, you can change the status of the procedure to EO.
  • Condition (Cn): Chart caries and other conditions as a separate step in order to see them on the graphical tooth chart. Most offices will not use this status. To use this status, you must also add dummy Procedure Codes that represent the conditions you are trying to show. The mouth area and paint type of each dummy code must be carefully set.
  • Treatment Planned Inactive (TPi): Procedures that are not part of an active treatment plan.

The procedure status determines the color used on the Graphical Tooth Chart.
Manually changing a procedure status to 'Complete' only changes the status. It does not change procedure dates or copy default procedure notes.

Set Complete: Assign the status of complete, insert default Procedure Notes, change the 'Date Entry' and 'Date' to today's date, and close the window.

Referral: Click […] to refer this procedure to a Referral source. Referrals out can be Tracked individually.

User: Identifies the User who last created or edited the Notes (below). It does not apply to the overall procedure.

Notes: This Text Box is for Procedure Notes and is usually empty until the procedure status is Set Complete. Once set complete, default procedure notes are automatically copied and staff can make changes to the notes as needed. If a default procedure note contains an Auto Note (and the preference 'Procedures Prompt for Auto Note' in Chart Module Preferences is checked) reopening the procedure will trigger any auto note prompts.

  • To create default procedure notes, see Edit Procedure Codes.
  • User: The user tied to the electronic signature (see below).
  • Click Auto Note to insert an auto note.
  • If a note contains quotes “”, then information must be filled in between the quotes or the note is considered Incomplete. To print incomplete notes, see Incomplete Procedure Note Report.
  • If EHR is turned on, this box is searchable. Click Search, enter the search string, then click OK. The first matching result will highlight.
  • If the procedure was created or completed today, the cursor will automatically show at the end of the note. Otherwise, the cursor will automatically show at the beginning of the note.

Viewing Old, Signed Procedures: In version 13.1, the Notes box was enhanced. As a result, if you open a procedure created before the update, the note may be changed. Sometimes hidden characters are added or removed. Make sure to click Cancel instead of OK when exiting the window so the note is not permanently changed. Otherwise, the hidden characters will be saved, and the change to the note will invalidate any digital signature.

Signature: Sign the note electronically (see Electronic Signatures). The user tied to the note is indicated in the User box above the Notes area. By default this is the logged on user. To override the user, click [...] then enter log on credentials. If a note is edited later, the signature will be cleared.

Tabs:

  • Financial Tab: View and add insurance estimates, adjustments, payments, and Procedure Discounts.
  • Medical Tab: To view this tab, Medical must be turned on in Show Features. Use it to attach ICD-10 diagnosis codes to the procedure (if required by insurance) or enter other other medical claim information.
  • Misc Tab: Medicaid and public health options.

Delete: Hide this procedure. The procedure will appear to be deleted, but will actually be hidden. Be very careful to make sure you don't lose any clinical information and that the Account remains accurate. Deleted procedures can only be viewed in Audit mode on the Show tab.

 

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