Procedure

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.

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.

Time Start: Enter the start time. End, Now and Final only show when Medical Insurance is turned on. Now inserts the current time. The Final field automatically calculates the total minutes.

Original Date Comp: Only shows for procedure that are complete, if the Date changes.

Procedure/Description: Click Change to select a different procedure code from the Procedure Codes. 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 Incorrect Procedures on 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 Procedure over Multiple Appointments.

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.

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 security permission.

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

Clinic: The clinic associated with this procedure. Only visible when Clinics is turned on.

Provider: The provider associated with the 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 Types. 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 Prosthesis. 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 Claim.

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


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 last associated with the Notes and tied to any electronic signature (below). Defaults to the logged-on user. To override the user, click [...] then enter log-on credentials.

Notes: For Procedure Notes. 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.

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/Initials: Sign the note electronically (see Electronic Signatures). The user tied to the note is indicated in the User box above the Notes area. If a note is edited later, the signature will be cleared.

Tabs:

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 Chart Views.