Follow the procedure below to make procedures and diagnoses for an encounter “Ready for Billing” in PCC EHR. These steps are typically performed by the clinician, though other staff may perform some steps.
Watch a Video: Watch Billing in PCC EHR to learn how to fill out the electronic encounter form make charges ready for billing. For an overview of the Post Charges billing workflow, watch Post Charges in PCC EHR. You can also watch phone consultation and telemedicine demos.
Enter Diagnoses, Procedures, Labs, and Other Orders
As you chart your visit, enter diagnoses and select labs and other procedures that require billing.
Did You Know?: You can add diagnoses directly to the patient Problem List or Allergies list whenever you chart diagnoses.
When you are ready to review what will be sent to billing and select a visit code, click the “Bill” button.
One User: To prevent over-writing each other’s work, only one PCC EHR user may open a particular visit’s Bill screen at a time.
Review and Update Selected Diagnoses
Review all the diagnoses that came from the chart. For each diagnosis, you will see an associated billing code (ICD-10).
Enter Diagnoses on the Chart Note: If you missed a diagnosis, you should close the encounter form and add the diagnosis to the chart note. PCC EHR adds all charted diagnoses to the electronic encounter form. You can enter new diagnoses on the EEF for specific billing situations, but those items will not become part of the patient’s medical record unless noted on the chart note.
No Billing Code?: If a diagnosis does not have a mapped billing diagnosis, you can select it on this screen:
Or, you can simply forward the SNOMED description for your billing staff to process.
Review Procedures and Select a Visit Code, Supplies, and Other Items
In the Procedures section, review all orders or other billable procedures that came from the chart note.
Next, select any additional procedures needed for billing purposes. For example, you should usually select a visit code, such as an OV, phone consult, or similar code for the encounter.
Why Did Certain Procedures Appear?: Your office’s encounter form configuration determines which procedures appear when you order each lab or other procedure, along with what additional optional items will appear because of those orders. You can edit your encounter form settings using the Billing Configuration tool.
Are the Labs Complete?: Procedure codes for your orders will appear on the electronic encounter form as soon as they are ordered. Your staff may have not yet completed the labs, immunizations, or medical procedures. Review the chart note, the Visit Tasks queue, or the appointment’s Edit Orders window to check the status of orders.
Well Child Code: The encounter form can automatically display the age-appropriate Well exam code, as shown in the screenshot above, or you may see a list of well visit CPT codes.
Customizable: Your electronic encounter form is customizable. You can add your most common procedures to save time. Learn more by reading Configure Billing in PCC EHR or contact PCC Support for assistance.
Optional: Add Unusual Items
The encounter form only displays your practice’s preferred procedures. Click in a blank field and enter a name or code to search for less-common procedures.
Click “Next” to continue to the second step of the Bill window.
Link Diagnoses to Procedures, Adjust Units
On the Linking and Units screen, use the line letters (a, b, c, d…) to indicate which diagnoses should link to each procedure.
You can type the letters in the field or click and drag each diagnosis to related procedures.
After making your selections, you can confirm that the appropriate diagnoses appear underneath each procedure on the right.
You can also adjust units for each procedure using the numeric field next to each procedure.
The 1-Diagnosis Trick: PCC EHR tries to help you link diagnoses, when it can. If a visit only has one diagnosis, it will place the appropriate letter in the field for all procedures.
Optional: Save and Close the Encounter Form Without Making it Ready For Billing
Do you need to go back to the chart note and update something? Click “Save + Exit” to return to the chart note without releasing the procedures and diagnoses for billing. You can reopen the Bill window when you are ready to make the encounter ready for billing.
Make Ready for Billing
Click “Make Ready for Billing” to change the status of the encounter. Your billers will then be able to post the charges.
Optional: Add Additional Items, Grab Back the Encounter Form
If you missed a diagnosis or procedure, you can add them to the chart note. PCC EHR will make any new diagnoses or procedures available to the checkout staff, though they will appear as unlinked.
Optionally, you can click “Edit Billing” to pull back the encounter form before the charges are posted. Then you can clean up your additions and perform linking.
While you are editing the electronic encounter form, other PCC EHR users can not select the visit and post charges. (Users can still post charges for any account manually, however.)
Sign the Chart Note
When you are finished charting, click “Sign” and sign the chart note. In addition to this being a general best practice, your billing staff can see the signers and co-signers for each encounter and may use that as a signal to know an encounter is ready to be billed.
Select Visit and Post Charges
Next the checkout or billing staff selects the visit and posts the charges.
For an example and a complete guide to all the Post Charges tools, read Post Charges in PCC EHR.
Review Encounter Form Charges, Add Additional Items
After your practice posts charges for an encounter, the clinician can no longer make changes to the electronic encounter form. However, any user can click “Billed” at the bottom of the chart note to review it.
Also, the clinician can still chart new diagnoses and procedures. Billers will see the “New Items” status and can add the diagnoses and procedures to the claim.