You can add a procedure to a patient chart from the Procedures module. You can also add procedure to a patient chart on charge submission of an order from the Orders module. The information entered in the Procedures module fields appears in the procedures list on the Procedures window. You can scroll across the procedure list area to view all the columns. The procedures you add also appear in the selected encounter for the patient and in the Superbill module.
- Open the Procedures module.
- Enter or select a procedure.
- To select the service date, do the following:
- Select the ellipsis button to display the calendar.
- Select a date.
- Select OK.
- Select Start/Stop Time.
Note: When you select Start/Stop Time, the current time is selected by default. To change a time, you can select the hours, minutes, and AM/PM fields and then select the up or down arrow.
- To select Fee, do the following:
- Enter a fee or select the ellipsis button.
- In the Fee field, enter the fee or select a value from the list.
- Select OK.
- Enter the place of service (POS) in the P.O.S field.
Note: If you change P.O.S from facility to non-facility and non-facility to facility, Fee is automatically updated.
- In Units, enter the number of units the procedure requires.
- To bill for clinical inventory, select the Rx on File check box.
Selecting Rx on File indicates that a prescription for the item is on file. The presence of a prescription directly affects whether a tax is associated with the transaction.
- Select NDC ID.
- Select Suppress Billing if you do not want to charge for the procedure.
Note: When you select Suppress Billing, NextGen® Enterprise EHR does not submit billing information to your billing system.
- Enter the Location and Provider values, if different than the default value.
If you change the location for the selected procedure, and the new location does not match the previous one, a message appears stating that you can update the P.O.S and the Fee values. Do one of the following:
- To update the P.O.S and the Fee values based on the setting in File Maintenance (Facility Place of Service versus Non-Facility Place of Service), select Yes.
- To retain the P.O.S and the Fee values, select No.
- In Status, select one of the following:
- Completed
- Preparation
- In Progress
- Not Done
- On Hold
- Stopped
- Unknown
Note: The default status for a new procedure is Completed.
- Enter or select diagnosis.
- Select Present on Admission.
The
Present on Admission Diagnosis window opens.
Note: For POA, you must select the Enable Present on Admission in Procedure Module check box under the EHR tab in thePractice Preferences window in File Maintenance.
For more information, go to NextGen Healthcare Success Community, and download the latest File Maintenance Preferences Guide forNextGen®Enterprise.
- Select the value for POA and select OK.
- Select modifier.
- In Notes, enter additional notes as needed.
- To add the procedure to the patient chart, select Add.
- If it is selected, clear the No Known Procedures check box.
Note: The check box does not automatically clear when you add procedures.
