Editing Procedures  

Procedures are entered from the Chart module, and you can also edit an existing procedure by double clicking it in the Account module, the Treatment Plan module, or the Chart module.

Procedure Code
If you have already entered a procedure and need to change the Procedure Code, use the Change button. This also updates the fee. Guidelines for entering procedures that involve multiple appointments are in the Lab Case section.

Your options for tooth number and surfaces might be different depending on how the procedure code for that procedure is set up. For instance, you could also have tooth range, arch, sextant, or quadrant options. See Procedure Code setup for more details.

Tooth Numbers and Supernumerary Teeth
If the Procedure Code treatment area is set to surface or tooth, then you will have a box to enter a tooth number. If you are outside the U.S., then you will probably be using international tooth numbers which are enabled in Module Setup. But for the American Universal system, the valid tooth numbers are 1-32 and A-T. For supernumerary teeth, the valid values are 51-82 and AS-TS. Permanent supernumerary tooth numbers are arrived at by adding 50, and primary supernumerary tooth numbers are created by adding an S. Procedures for supernumerary teeth do not show on the graphical tooth chart, but they do get billed to insurance.

Status
The procedure status can be one of the following:
   TP - Treatment Plan - for work that is recommended, but not complete yet.
   C - Complete - the fee for the procedure will show on the patient's account.
   EC - Existing Current Prov - work that was done in your practice before you started using Open Dental.
   EO - Existing Other Prov - work that was done by another provider, either before the patient came to your practice, or because they were referred out for treatment.
   R - Referred Out - work that the patient needs done, but that will be done at another office. Once the work has been completed, you can change the status of the procedure to EO
   D - Deleted - Procedures are set to this status instead of actually being deleted.  Can only be seen while in audit mode.
   Cn - Condition - Some offices prefer to chart caries and other conditions as a separate step in order to see them on the graphical tooth chart.  Most offices will not use this status.  If you feel that you need to use this status, you will need to add some dummy Procedure Codes that represent the conditions you are trying to show.  The mouth area and paint type of each dummy code must be carefully set. 

Medical
See the Medical Insurance page if you intend to send medical claims. On the screen above, you will need to fill in a medical code, a diagnostic code, and assign one procedure for the day as having the principal diagnosis.

Diagnosis and Prognosis
You can select one diagnosis for a procedure. The items on this list are set up from the definitions area in the Tools module. If a procedure requires more than one diagnosis (for instance: cracked tooth, IP, Apical perio) you could add the additional diagnoses as notes in the procedure. Diagnosis fields will not affect the visual display. If you want to see diagnosis separately from the proposed treatment, see the comments above regarding the Cn Status.

Prognosis is not used by most offices, although it seems to be required in some states.  If it is required to show on the treatment plan, then use the Display Fields to add a prognosis column to the Treatment Plan module main grid.  To speed entry, prognosis can be set when Entering Treatment.

Provider, and Priority
One provider is selected from the list. The provider might be changed later when scheduling the appointment.  Usually, the provider will already be selected based on the patient's provider. The priority is used to prioritize treatment in the Treatment Plan module.

Place of Service, Clinic, Prosthesis Replacement, and Referral
The Place of Service and Clinic will only be visible if Clinics are set to be visible in Show Features. There is a default place of service for the Practice, as well as an override for every clinic. The place of service for the procedure gets set when it is marked complete, and can then be changed if needed.

The Prosthesis Replacement section in the middle will only be visible if the Procedure Code for this procedure has been set up ahead of time as a prosthesis procedure. This forces users to enter the needed prosthesis information before the Claim will be allowed to be Sent electronically.

Any procedure may be referred out and Tracked individually.

Notes
The note area is usually empty until the procedure is marked complete, at which time the procedure note is entered. See the section on setting appointments complete for more information about procedure notes.  See Procedure Group Notes for information on how to make a single note that covers multiple procedures.  See the Notes Overview for information about notes in general.

All notes are always saved and cannot be deleted or changed by anyone, no matter what their Permission level. But users will not notice this high security level. From their perspective, all notes can be edited, but internally, all versions of their changes get saved permanently. To see a history of all changes and deletions, use the audit checkbox in the Show section of the Chart module.

In addition to using default template notes, you can also use scripted Auto Notes.  Below are some examples that show the difference between template notes and Auto Notes.

Strategy 1: Fill in the blank. This is an excellent strategy.
Comprehensive Exam
Medications:
Allergies:
Medical Conditions:
PSR:
Overall PSR:
Soft Tissue Screening:
Dental Exam: Treatment plan printed.
Pt Concerns:
PARQ: ""

Strategy 2: Prefilled. Slightly more efficient, but with negligible benefit. Risk of inaccurate notes.  Possibly better "completeness" of notes, even if inaccurate.
Comprehensive Exam
Medications: none
Allergies: none
Medical Conditions: none
PSR:222222
Overall PSR:2
Soft Tissue Screening: WNL
Dental Exam: No caries. Treatment plan printed.
Pt Concerns: None
PARQ.

Strategy 3: Scripted.  See AutoNotes.
Comprehensive Exam
Medications: (pick from list)
Allergies: (pick from list)
Medical Conditions: (pick from list)
PSR:222222
Overall PSR:2
Soft Tissue Screening: (pick from list)
Dental Exam: No caries. Treatment plan printed.
Pt Concerns: None
PARQ.

Claim Notes
The claim note is for short notes that pertain to this procedure and should be sent with the Claim. It should be used rarely. The note will not be printed on paper claims because there is no place for it.  It is a procedure level note, not a claim level note.   It will be sent with e-claims because e-claims have a field for procedure level notes.  On e-claims, the claim level note will also be sent.

The Delete button to the lower left will delete (actually just hide) this procedure. You would want to be very careful when doing this to make sure that you don't lose any clinical information and that the Account is accurate.

See the Digital Signatures page for information on how to sign your notes if you wish.

Insurance Estimates and Payments, Patient Payments, and Adjustments

This is a list of Claim Procs. See that section for detailed information. In essence, each row is either an estimate or has been attached to a Claim. Estimates are explained below, but if an procedure has been attached to a claim, then you have to edit the Claim Proc from within the Claim.

If you see items in the list with a status of Est, then you can safely edit or delete them since they have not yet been attached to a claim. Estimates are usually handled automatically by Open Dental, so if the estimate doesn't look right, or is missing, you should probably make sure the Insurance Plan is set up correctly instead of editing estimates manually. If you entered a treatment plan before entering the insurance plan, and the estimates still don't look correct, try clicking the Update Fees button in the Treatment Plan module.

The second situation where you would manually edit an estimate is if you want to override the computed estimate. The insurance plan may be set up correctly, but you still need to change something. Maybe you got a pretreatment estimate back from insurance or you have a fee schedule to follow. Double click on the estimate and in the Claim Proc window, change Override Ins Estimate to the amount you want. You also have many other override options in that window, including overriding the percentage, the allowed amount, the copay, etc.

You can also attach paysplits and adjustments to individual procedures. Paysplits must be attached from within a PaySplit when entering the payment. Adjustments are simpler and can be attached directly from the procedure window using the button at the bottom.