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

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

NextGen® Orthopedic Suite Help 80.2.14.0

Add a New Diagnosis

You can add a diagnosis for today’s visit. On the Assessment and Plan panel, to filter the patient's diagnoses, select one of the following options above the Diagnosis grid: Orthopedic Medical Click Add under the Diagnosis grid to launch the Common Assessment template or click ProblemIT if using IMO. Select a diagnosis or diagnoses to add to the patient’s diagnosis histories. Click Save & Close. Parent topic: Assessment and Plan Panel (Diagnosis/MDM)

Assessment and Plan Panel (Diagnosis/MDM)

Recommendations

Risk of Complications - MDM

Assessment and Plan (MDM) Panel

Document Diagnosis Management

Data Review

Generate the E&M Code

Add a New Diagnosis

Risk of Complications - MDM

Assessment and Plan (MDM) Panel

Document Diagnosis Management

Data Review

Generate the E&M Code

Add a New Diagnosis