NextGen 5.8 Ambulatory EHR Procedures Modulecoursedev.nextgen.com/LMS/.../5.8ProceduresModule... · Confidential – Proprietary Information – For Use By Authorized NextGen Healthcare

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November 2015 Page 1 of 7

NextGen® Ambulatory EHR Procedures Module

NextGen® 5.8 Ambulatory EHR Procedures Module

Introduction

The Procedures module is used to record all of the medical procedures associated with a patient. You can:

Add, update, and delete a procedure

Add up to twelve diagnoses and four modifiers to the procedures

Enter a past, current, or future Service Date

Right-click a procedure to access Provider/Education resources

Please note that only the Procedure, Service Date, and Provider fields are required.

To Access the Procedures Module

1. Click the Procedures icon on the History toolbar.

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February 2015 Page 2 of 7


Procedures Module Field Definitions: Procedure: Displays the procedure code. To add a new procedure, click the ellipsis, then search and select the procedure to add.

Service Date: This field defaults to the encounter date. To change the date, click the ellipsis to prompt the pop-up calendar, then select the desired service date. Procedures can be entered for a past, current, or future date. A Service Date is required for all procedures.

Start/Stop Time: If selected, the Start/Stop Time check box enables the Start/Stop Time fields to allow entering the time frame to support timed based billing for general behavioral health.

Fee: When a new procedure is added, the Fee field is populated with the fee associated with the procedure. You can change the fee if needed.

P.O.S.: This field displays the Place of Service code.

Units: You can enter the number of units per procedure.

Rx on File: This check box is an indicator for the user to specify whether a prescription for a clinical item is on file. If you want to bill for clinical inventory (e.g. casts, prosthetics), the prescription for the item must be on file before a claim is sent.

NDC ID: The NDC ID (National Drug Code ID) field provides the ability to enter an NDC ID for the drug used in the procedure in the Procedures module. You can click the ellipses button next to the field to search for an NDC ID.

Location and Provider: You can change the location and provider if different from the EHR default.

Diagnosis: To enter a diagnosis for the procedure, click the ellipses button, then search and select the diagnosis to add. You can add up to twelve diagnoses per procedure.

Modifiers: To enter a modifier for the procedure, click the ellipses button, then search and select the modifier to add. You can add up to four modifiers per procedure.

ICD-10 Code Mapping

The Procedures module helps to prevent the use of ICD-9 codes by automatically converting codes that have one-to-one mapping, or by allowing you to choose the appropriate code for those with a many-to-one mapping.




Follow these steps to map ICD-9 procedure codes to the appropriate ICD-10 code:

1. Enter the ICD-9 code for a procedure.

2. Click Add.

3. If the code can be mapped to

multiple ICD-10 codes, the Procedure Charge Mapping window opens. Click the ellipsis (…).

4. Click to select the desired

Scenario check box. 5. Click OK to accept the Scenario.

6. Click OK to close the Procedure

Charge Mapping window.

The ICD-10 codes are now displayed in the Diagnosis fields.




To Add a Procedure

1. Open the Procedures module. 2. Click the ellipsis (…) button next

to the Procedure field to open the Select Procedure window.

3. Enter the procedure code or

description into the Description field to search.

4. Double-click the appropriate procedure from the search results list. The window will close.

5. To enter a diagnosis, click the

ellipsis (…) button next to the Procedure field. The Patient Diagnosis List pop-up window opens.

6. Click the desired diagnosis. 7. Click Select. The window will

close.

8. To enter a Modifier, click the

ellipsis (…) button next to the Modifiers field.




9. Search for a modifier by Modifier Key, Description, or by scrolling through the results list.

10. Double-click the desired modifier. The window will close.

11. Click Add.

The procedure is added to the Procedure list.

To Update a Procedure

1. Click the Procedure from the Procedure list.

2. Click the ellipsis (…) button next to the Fee field to open the Fee window.




3. To zero out the charge amount, click OK. The Fee window will close.

4. Click Suppress Billing. 5. Click Update. The procedure is

updated.

To Delete a Procedure

1. Click the Procedure from the Procedure list.

2. Click Delete. A confirmation window opens.

Note: You cannot delete a procedure if the Encounter is locked.

3. Click Yes to confirm the deletion

of the procedure. The procedure is deleted.




To Enter the National Drug Code (NDC) ID Code for a Procedure

1. Create a procedure with the proper Procedure, Diagnosis, and Modifier codes.

2. Click the ellipsis (…) button next to the NDC ID field to open the Select National Drug Code ID window.

3. Enter the drug Description, NDC

ID code, or CPT4 code. 4. Click Search. 5. Double-click the drug. The

window will close.

6. Click Add. The procedure is

added to the Procedure list.

Documents

NextGen 5.8 Ambulatory EHR Procedures Modulecoursedev.nextgen.com/LMS/.../5.8ProceduresModule... · Confidential – Proprietary Information – For Use By Authorized NextGen Healthcare