Document a Generic Procedure

You can document the details of the procedures that have no specific procedure templates on the Generic - Procedure template.

1. Open NextGen® Enterprise EHR.
2. Open the SOAP template.
3. Select the icon and select the Procedures link from the navigation bar.
   The Procedures template opens.
4. Select Generic.
   The Generic - Procedure template opens.
5. In the Procedures section, do the following:
   1. Select the Procedure description field to search for and select a procedure.
      The application automatically fills Code with the CPT 4 code for the selected procedure.
   2. Select the modifier codes in Mod 1 and Mod 2.
   3. Enter the supporting codes for the selected procedure and add the modifiers in the corresponding fields in the Additional Codes fields.
6. In the Pre-procedure care section, select the appropriate check boxes after explaining the procedure details to the patient.
   • To add more information about the consent, select the Consent link .
7. In the Indications section, do the following:
   1. Select the Description field to search for and select a diagnosis.
      The application automatically fills the Code field with the relevant diagnosis code.

      You can add up to 4 indications for the procedure; you must enter at least one indication.

   2. Select the status for each of the selected diagnoses.
   3. Enter the procedure notes manually or use My Phrases.
   4. For Anesthesia, enter the required details and select appropriate check boxes.
      Note: If the procedure is performed without anesthesia, select the None check box.
   5. Enter the procedure findings or use My Phrases.
   6. Enter the complications of the procedure.
8. After the procedure is performed, document the post procedure details in the Post Procedure section:
   1. Enter the Instructions and Dressing/wound care details manually or use My Phrases.
   2. Enter the follow-up details, and then select Add.
9. To submit the procedure charges, select Submit to Superbill.
   Note: A green check mark with the submitted status for the procedure indicates that the charges are submitted successfully.
10. To save the information and close the template, select Save & Close.