Risk of Complications

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

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

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

NextGen® Orthopedic Suite Help 80.2.14.0

Medical Decision Making (MDM)

You can enter plan information. A plan may include any verbal counseling done, medications, office procedures, diagnostic tests, labs, DME, patient education, and designated follow-up visits. You can enter data in these ways: Click Get Data to load in MDM information from previous encounter. Click the star or double star icon in the QuickPick toolbar to load a template default. Select radio buttons, click fields to select entries from picklists, or click fields to type comments or add additional items. The fields are all picklist-driven and configurable in the Picklist Configuration template. Parent topic: Assessment and Plan Panel - Single Fracture

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

Medical Decision Making

You can enter in the plan information. Each body area has its own plan section. The plan includes any verbal counseling done, medications, office procedures, diagnostic tests, labs, DME’s, patient education, and an area to designate follow-up visits. These fields are all picklist-driven and fully configurable within the Picklist Configuration template. You can enter data multiple different ways: Click each field to select items from configurable picklist. Click on the star or double star icons in the QuickPick Toolbar at the top of the Fracture Care template or from the MDM button that opens the MDM template to load a template default. Click the MDM button to launch a template where you can use the Get Data button to load MDM information from previous encounter. Parent topic: Assessment and Plan Panel for Poly Trauma

Risk of Complications - MDM

Recommendations

Add a New Diagnosis

Assessment and Plan Panel (Diagnosis/MDM)

Document Treatment Plans

Medical Decision Making (MDM)

Assessment and Plan (MDM) Panel

Medical Decision Making

Risk of Complications - MDM

Add a New Diagnosis

Assessment and Plan Panel (Diagnosis/MDM)

Document Treatment Plans

Medical Decision Making (MDM)

Assessment and Plan (MDM) Panel

Medical Decision Making