Assessment and Plan Panel (Diagnosis/MDM)

NextGen® Orthopedic Suite Help 80.2.14.0

Risk of Complications - MDM

This section captures your plans to treat the patient for today’s visit. It includes any verbal counseling done, medications, office procedures, diagnostic tests, labs, DME’s, patient education, etc. and an area to designate follow-up visits. These fields are all picklist-driven and fully configurable within the Picklist Configuration template. Note: For more information, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Orthopedic Suite. Document Treatment Plans Parent topic: Assessment and Plan Panel (Diagnosis/MDM)

NextGen® Orthopedic Suite Help 80.2.14.0

Assessment and Plan (MDM) Panel

The Assessment and Plan panel enables the provider to select the diagnosis for today’s plan, and enter today’s plan, next visit information, and verbal counseling. Assessment and Plan panel on the Non Billable Visit template The Diagnosis grid shows the patient’s diagnoses. The system defaults to the Orthopedic option to view Orthopedic-specific diagnoses. The Medical option displays other diagnoses. Add a Diagnosis to Plan Enter Plan Information Parent topic: Non-Billable Post-Op Visit Workflow

NextGen® Orthopedic Suite Help 80.2.14.0

Document Diagnosis Management

Select one or more diagnoses from the Diagnosis grid to enter them in the B-Diagnosis/Mgmt section. Diagnosis Management on the Billable Visit template For each diagnosis in the B-Diagnosis/Mgmt section, select an option to describe the diagnosis: Self lim- self-limiting Est Stab– established, stable Est Wors– established, worse New New WU- new with work up The E&M points appear in the fields after the diagnosis descriptors. Parent topic: Assessment and Plan Panel (Diagnosis/MDM)

NextGen® Orthopedic Suite Help 80.2.14.0

Data Review

You can document, data reviewed to increase the E&M Level, under the A-Data Reviewed section. Data Review on the Billable Visit template Select the check boxes next to the items reviewed during today’s visit. As you select items, the points appear in the corresponding field. Note: The check box for CPT7 is automatically selected if X-rays were ordered on today’s visit. The blue information icon offers more information on what is considered a CPT7, CPT8, or CPT9 lab. Parent topic: Assessment and Plan Panel (Diagnosis/MDM)

NextGen® Orthopedic Suite Help 80.2.14.0

Billable Visits

The Billable Visit workflow starts on the Billable Visit template. This template is used to document the History of Present Illness (HPI), Physical Exams, and Assessment and Plan portions of an E&M coded visit. It pulls in information from the Intake template. It has three panels: History, Physical Exam, and Assessment and Plan. Documenting Visit Time You can enter the visit time for a patient's visit on the Billable Visit template. Patient History You can review, add, and update the patient histories. Physical Exam Panel Assessment and Plan Panel (Diagnosis/MDM) Billable Visit Sign-off Documenting Billable Visit Counseling You can document the additional counseling time and its associated details for a patient. Finalizing a Patient Visit You can enter a patient's visit details and today's diagnoses, and apply diagnosis codes to procedures to submit charges and finalize the visit. Parent topic: Using NextGen Orthopedic Suite

NextGen® Orthopedic Suite Help 80.2.14.0

Generate the E&M Code

In the lower part of the Assessment and Plan panel, click the E&M Key button to generate the E&M code. This searches the entire visit, the History, Exam and Assessment and Plan sections, verifying what information has been entered (noting the green indicators), to determine a suggested E&M code. E and M code on the Billable Visit template The system gives a value (or points) for History, Exam, and MDM, and a Final Code based on the information documented. Note: If you update histories, exams or MDM after clicking the E&M Key button, click the button again to update the code. View E&M Summary and Coding Guidelines You can view the details of a patient's visit, medical decision making (MDM), and evaluation and management (E&M) coding guidelines. Parent topic: Billable Visit Sign-off

Assessment and Plan Panel (Diagnosis/MDM)

Recommendations

Risk of Complications - MDM

Assessment and Plan (MDM) Panel

Document Diagnosis Management

Data Review

Billable Visits

Generate the E&M Code

Assessment and Plan Panel (Diagnosis/MDM)

Risk of Complications - MDM

Assessment and Plan (MDM) Panel

Document Diagnosis Management

Data Review

Billable Visits

Generate the E&M Code