Home Forums Discussions General Discussion Mainly Procedure based office

Hi we are just starting out with AC and are currently in the trial phase, so far so good, just a few ?? if anyone can help.
#1 we are mainly a procedure based practice (Dermatology. The way AC is set up seems more geared to office visit. Where within the note are most putting the procedures? We have been putting them in the assessment section and this seems to work, but wondered if there were any better ideas.

#2 I am a little confused by the double "sign screen" once the provider signs the chart, it opens a second screen for billing input. Since we are using our own PM and still have old fashioned paper superbills to be used up we weren't going to use this portion at least for now. However it seems that unless it is signed also, the encounter does not save? Does it need to be signed? If it is signed can the codes be changed later if nec? Also does it need to be filled in to accurately reflect for MU?

#3 I thought I had seen somewhere on this forum, but now I can't find it, the ability to create a chart note in word and then input it into the chart, using keywords and > shortcuts to allow the program to insert in the proper spot. Is there anything like this?

And finally, is there a way to set up a default patient? We are a derm office and would like to have the front back body illustration automatically in place for each encounter. It is not a big deal but would be great if it could be defaulted.

Thanks in advance for any help anyone can give!

Well you will probably get better answers but since nobody's responded yet I'll take a crack at this.

#1 I generally put procedures in the PLAN section and make templates for the ones I do commonly. I don't see a problem putting them in the assessment section though, although I generally reserve that for diagnoses and elaboration on what I think is going on.

#2 I also still use the paper superbills and give them to our billing service. Since the great majority of codes I use are common E@M codes I usually go ahead and enter those anyway on the billing screen since it is nice for my staff to be able to refer back in AC and see what I coded. For things I don't do that commonly I just go ahead and hit save (on the pop-up billing screen) - a window comes up asking if I want to enter a CPT code and I answer NO - the note then saves, and I manually enter the CPT on the superbill. For stuff I don't do commonly I have to go back to my coding guide and look them up. You can find them in AC but the book is easier for me to find codes.

#3 Can't help you there, don't need or use that feature very often. Seems like you could have the nurse put it in there when the patient is checked in if there's not a more elegant way to do it.

1 - I make templates for most procedures and place them in addendums, then in the Plan I put something like the following:

Exam, history and chart reviewed.
Recommend Suture repair of wound.
Recommend Lesion removal, etc.

Then an addendum is created with PROCEDURE, subject: Suture Repair of wound.

That way there is no question as to separately identifiable procedure vs E&M.

2- I believe you must have at least one code entered before signing off for that chart to be counted as MU - you can change.

3- I know of no way to do this currently.

#1) We do not do that many procedures but put them in the physical section. That's totally user preference.

#2) At one time you could skip the billing section, but not now. Probably has to do with meaningful use.

#3) cut (Control X) and paste (control V) are your best friends.

As Wendell alluded to, user preference is the key phrase. MU may change the playing field for some, but I finally concluded that AC is just a database, and it is there to serve my wishes, not vice-versa. The assessment section works for me personally as a problem list, and since we do use the billing section, it populates that as well. My partners prefer to put the problem list in the past history section, and that has its advantages as well. I use the plan section to discuss my impressions, what I am doing, and why. My procedures mostly come from the hospital, and I print the procedure note to a PDF file there and import it into the Imported Items section.

1. We put procedures under ADDENDUM - as this asks for its own Coding for creation of superbills and cross reference procedure in the PLAN section of the main note on the same date and use modifier as appropriate. We use AC superbills and send these electronically to our outsourced billing company.

2. We find it very USEFUL to have AC put the CPT and ICD-9 codes for us in the superbill so information transfered to billing company reflects the one we are putting in the chart.

3. We use Dragon Medically Speaking - a great progam - just place your cursor into the desired field and dictate. Accuracy is great after you have trained it.

Katy,
1. So you can see that this is one of those situations where you have a lot of choices. Like David, I do my procedures outside of the office so it is easiest to import them as pdf's to Imported Items. There is no right or wrong here.

2. You ask several questions here and the answer is a little complicated. After writing a note, you MUST sign it to permanently save it. (If your provider has not been signing the notes, then they have not been saved). You MAY add a cpt and diagnosis code, but you are not required to do so; the note will save without it.
Putting MU aside for the moment, if you are using a separate practice management program, you can leave the codes out and put them on a paper superbill that goes to your biller, (this is what we do) or you can put them into AC and they are accessible there. Others please correct me if I am wrong here...I think you can edit billing and diagnosis codes later, after signing the chart, if you choose to.
With regard to MU...it appears that for your CQM's and Menu items to count appropriately, in many cases you must have coded the diagnosis and E and M codes. Diagnosis must be correct (e.g. how can the program tell if you have gotten eye exams on your diabetics if you didn't code the diabetes). On the other hand, if the CQM items you use are not "diagnosis-specific" then you need not include the diagnosis codes at all. You do need to include a CPT. This need NOT match the cpt that you put on your paper superbill and submit for billing; you can just pick one when the provider signs off.
Sorry....MU makes this a bit confusing.

3. As the others say, AC does not allow this...except "section by section", cutting and pasting from Word to AC.

Thanks to all who responded. I really appreciate all the help this forum brings!