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.
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.
To use international tooth numbers, or for information on valid tooth numbers or supernumerary teeth, see Chart Module Preferences, Tooth Nomenclature.
Hide Graphics: Check this box to hide this procedure on the Graphical Tooth Chart.
Clinic: If using Clinics, the clinic associated with this procedure.
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.
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:
The procedure status determines the color used on the Graphical Tooth Chart.
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.
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.
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.
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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