Document Diagnosis Management
Select one or more diagnoses from the
Diagnosis
grid to enter them in the
B-Diagnosis/Mgmt
section.
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.
Recommendations
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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
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)
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 Panel (Diagnosis/MDM)
The Assessment and Plan panel has three sections to match E&M coding guidelines: Diagnosis/Management, Data Review, and Risk of complications. These allow the provider to document Medical Decision Making. The system calculates and records points for Diagnosis/Management and Data Review and assigns a level for Risk of complications based on your recorded plan to treat the patient. All of these are used to calculate the final E&M code. Assessment and Plan panel on the Billable Visit template Add a New Diagnosis Document Diagnosis Management Data Review Risk of Complications - MDM Parent topic: Billable Visits
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 Treatment Plans
In the Assessment and Plan panel, click a Medication Decision Making # link. Medication Decision Making on the Billable Visit template The IORTSMDM 1 template opens. IORTS MDM template Select one or more of Today’s Diagnoses in the upper left. Note: You can associate one diagnosis or multiple diagnoses with a plan. You can have up to eight different plans with eight different diagnoses if desired. Enter plan details for the diagnoses. You can enter data in the following ways: Click Get Data to fill the fields with information from a previous encounter with this patient. Click the Star or Double Star button in the QuickPick toolbar to load a template default. Select appropriate options, click the fields to select entries from picklists, or type the information in the field. Enter any check-out information using the C/O Info button. Enter in Follow-Up visit information and click Upload NV to send follow-up visit information to the Check Out template. Click Save & Close to return to the B
