Procedure

In the Chart Module, double-click a procedure to edit.

Alternatively,

To edit, delete, or set procedures complete, the logged-on user must have the correct Permissions.

Date

Date Entry: Initially this date is the day the procedure was entered. The date is updated when the procedure is set complete. It cannot be manually edited.

Date TP: The day the procedure was added to the treatment plan.

Date: Date of the procedure.

Time Start: Enter the procedure start time.

End: Only shows when Medical Insurance is turned on. Enter the procedure end time.

Now: Only shows when Medical Insurance is turned on. Inserts the current time. If no time exists in Time Start, button will insert time here. If there is already a start time, it will insert an end time instead. If both a start and end time exist, button will override the existing end time.

Final: Only shows when Medical Insurance is turned on. Automatically calculates the total minutes based on Time Start and End.

Original Date Comp: Only shows for Complete procedures if the Date changes. Displays date procedure was originally set complete. Cannot be changed

Procedure and Treatment Area

Procedure: Procedure code of the attached procedure.

Description: Description of the attached procedure.

Change: Click to choose to a different procedure code from the Procedure Codes List. This will also update the Amount field.

Note: If the new code's treatment area is different, users will not be allowed to change it due to a treatment area mismatch. For example, a user cannot change a filling procedure to a prophy procedure, because the treatment area for a filling is Tooth and for a prophy is Mouth. Once the user attaches a claim to an incorrect procedure, it is more complex. See Incorrect Procedures on Claim.

Tooth/Surface: Options for tooth number and surfaces are different depending on the procedure code's Treatment Area set in Edit Procedure Code.

To use international tooth numbers, or for information on valid tooth numbers or supernumerary teeth see Tooth Nomenclature in Chart Module Preferences.

Amount: The billable fee of the procedure based on the fee schedule. Enter default fees in the Procedure Code List. The fee only shows if the logged-on user has the Show Procedure Fee security permission.

Hide Graphics: Check this box to hide this procedure on the Graphical Tooth Chart.

Diagnosis: Users can select one diagnosis per procedure. If a procedure requires more than one diagnosis (for instance: cracked tooth, IP, Apical perio) add them as notes. Diagnoses do not affect the graphical tooth chart. Customize options in Definitions: Diagnosis Types. To see diagnoses separately from the proposed treatment, see the comments regarding the Condition (Cn) Status.

Priority: Used to prioritize treatment in the Treatment Plan module. Options can be customized in Definitions: Treat' Plan Priorities.

Prosthesis Replacement

This area is only visible if the procedure code has been set up as Is Prosthesis. This information is sent in e-claims only and is required before sending electronically.

Crown Bridge, Denture, or RPD: Select Initial or Replacement. If No is selected when closing the Procedure Info window, users will be prompted with the window below. When attempting to save or send claims with the procedure attached, users will also receive a warning that the claim is missing data.

Original Date: Required when prosthesis is marked as Replacement.

Is Estimated: Check if Original Date entered is an estimate. The flag is only supported in 5010 e-claims. For 4010 e-claims, there is no place to send this flag, but it may be useful for documentation. Enter this information for printed claims on the Edit Claim - General Tab.

E-Claim Note

E-claim Note: A place for short notes that pertain to this procedure. Limited to 80 characters. It should be used rarely and is only sent in e-claims; it will not print on paper claims. The note is procedure level, not a claim level. To enter a claim note, see Edit Claim - General Tab.

Procedure Status, Provider, and Referral

Procedure Status: The procedure status can be one of the following:

Note: The procedure status determines the color used on the graphical tooth chart, with the exception of procedure using a color override. Manually changing a procedure status to Complete using the dropdown only changes the status. It does not copy default procedure notes.

Set Complete: Assign the status of complete, insert default procedure notes, change the Date Entry and Date to today's date, and close the window.

Clinic: The clinic associated with this procedure. Only visible when Clinics is turned on.

Provider: The provider associated with the procedure (i.e., treating provider).

Referral: Click [...] to refer this procedure to a Referral source. Referrals out can be tracked individually.

Notes

User: Identifies the User last associated with the Notes and tied to any electronic signature (below). Defaults to the logged-on user. To override the user, click [...] then enter log-on credentials.

Auto Note: Click to manually insert Auto Notes.

Edit Auto Note: Only appears when an Auto Note has been used and prompts have been left unanswered. Click to complete Auto Note.

Notes: For Procedure Notes. Usually empty until the procedure status is set complete. Once set complete, default procedure notes are automatically copied and staff can make changes to the notes as needed.

Signature/Initials: Sign the note electronically (see Electronic Signatures). The user tied to the note is indicated in the User box above the Notes area. If a note is edited later, or the user is changed, the signature will be cleared.

Tabs

Procedure - Financial Tab: View and add insurance estimates, adjustments, payments, and TP Procedure Discount.

Procedure - Medical Tab: To view this tab, Medical Insurance must be turned on. Use it to attach ICD-10 diagnosis codes to the procedure (if required by insurance) or enter other medical claim information.

Procedure - Misc Tab: Medicaid and public health options.

Save, Edit, or Delete

Delete: Delete the procedure. Deleted procedures can be viewed in Audit mode (see Show Chart Views), but cannot be un-deleted. If Appointments require procedures is enabled in the Appointments Module Preferences, users will receive the below message when deleting the last procedure attached to an appointment.

Edit Anyway: Button will only appear on procedures attached to claims or preauthorizations. Click to edit procedure information. Some fields (e.g., procedure code) still cannot be edited even after clicking this button. These fields will be greyed out.

OK: Close the window and save changes.

Cancel: Close the window. Some changes will not be saved.