Coding

Complete this task to code or enter information pertaining to an image set. This coded information will be transferred to cases upon creation of the charge batch and cases.

Step-By-Step Guide

Step

Instructions

Additional Information

1

From the Image Batches / Charge Batch tab, select the Batch with the relevant image set for coding.

2

Select the relevant image set of the selected Batch to code.

3

Click Code. The Coding tab opens.

4

General Information Section

This section is to collect the detailed information of the patient and key date and facility information. This information is not required in the Coding tab, but capturing it here will populate it into the associated case, saving you from having to enter it there.

5

Enter the Patient information (Last, First, Middle).

6

Enter the patient's SSN.

7

Enter the patient's DOB.

8

Enter the Date of Service that services were rendered.

9

Enter the Admit Date the patient was admitted to the hospital.

10

Enter the Discharge Date the patient was released from the hospital.

11

Enter the Charge Received date to designate when the charge was received.

12

Open the Referring Physician drop down list and select the referring physician on the case.

If the physician is not listed, use the icons to perform the appropriate actions:

- search for physician
- create new physician (open the Provider: New page)
- modify physician
- remove current selected physician

13

Open the Facility drop down list and select the facility where the patient was treated.

This step is only necessary if the facility is different from the default facility.

14

Enter the facility identification number assigned to the case in the Facility Case ID field.

15

Enter the external identification number assigned to the case in the External Case ID field.

16

Select the Emergency checkbox to indicate if the patient was treated under emergency conditions.

17

Enter the information to include in Box 19 on the paper claim form in the Box 19 field.

18

Open the Compensation Fee Schedule drop down list and select the correct fee schedule for compensation.

19

Procedures Section

This section is to collect the detailed information of the procedure and provider time related to anesthesia procedures.

20

To record a procedure on the case, click Add (or press [Alt] + D). The Add Procedure window opens.

21

Open the Code drop down list and select the appropriate procedure code from the list of procedures.

When selecting a procedure code that is a non-anesthesia code, the provider must be the same provider as the rendering anesthesia directing provider. This validation is done at the time of saving the case. If the provider for the procedure is different from the provider entered in the Anesthesia Case Provider Time section, a validation message appears. Click OK to close the message, and then click the applicable providers for both the procedure and anesthesia directing provider.

22

Open the Type of Service drop down list and select the type of service provided.

The Type of Service will default to a value based on the Code selected above.

You can manually enter the Type of Service and use the alphanumeric shortcut keys to quickly select the Type:

Type	Quick Key
Ambulance	D
Ambulatory Surgical Center (Facility Usage for Surgical Services)	F
Anesthesia	7
Assistant at Surgery	8
Consultation	3
Diabetic Shoes	J
Diagnostic Laboratory	5
Diagnostic Radiology	4
Enteral/Parenteral Nutrients/ Supplies	E
ESRD Supplies	L
Hearing Items and Services	K
High Risk Screening Mammography	B
Hospice	H
Immunosuppressive Drugs	G
Kidney Donor	N
Low Risk Screening Mammography	C
Lump Sum Purchase of DME, Prosthetics, Orthotics	P
Medical Care	1
Monthly Capitation Payment for Dialysis	M
Occupational Therapy	U
Other Medical Items or Services	9
Outpatient Mental Health Treatment Limitation	T
Physical Therapy	W
Pneumococcal/Flu Vaccine	V
Rental of DME	R
Surgery	2
Surgical Dressings or Other Medical Supplies	S
Therapeutic Radiology	6
Used DME	A
Vision Items or Services	Q
Whole Blood	0 (zero)

23

For an anesthesia procedure, open the ASA Code field, and select a code for the specified procedure.

24

(Optional) Enter the two-character code used to describe services associated with the procedure in the Modifiers field.

You can enter up to four modifiers. Each modifier must be two characters and be separated by a comma, for example: QK, QA.

To assign different modifiers to the Directed provider than the Directing provider, select the Override Directed checkbox and enter the applicable modifier in the field. This allows for billing both providers out on the same claim with different modifiers.

The following modifiers are invalid for anesthesia procedures:

TC
26
53

The following modifiers cannot be entered for anesthesia procedures unless the Exclude from Concurrency Checking option is selected on the case:

QY
QK
QZ
AA
QX
AD
Q6

25

Open the Place of Service drop down list and select the place of service for the facility.

This list contains the place of service types for the facility specified on the General Case Information tab.

By default, this field is blank for the first procedure. After a place of service is selected for the first procedure, that place of service becomes the default place of service for all other procedures on the case.

When rebilling a service line item without fee changes, you can change this field's value to a different place of service as long as the place of service type is the same, for example, facility or non-facility. You cannot change the place of service if either of the following conditions apply:

If the original value is a facility place of service, you cannot change the place of service to a non-facility place of service.
If the original value is a non-facility place of service, you cannot change the place of service to a facility place of service.

26

Open the Provider drop down list and select the provider who performed the general procedure on the case.

When rebilling a service line item without fee changes, you cannot change the provider.

27

Enter the date of service for the procedure in the Date of Service field.

This field is only available for general procedures, not anesthesia procedures. For anesthesia procedures, this column is updated from the provider time after it has been recorded in the Anesthesia Case Provider Time section.

When rebilling a service line item without fee changes, you cannot change the date of service.

28

Place your cursor in the ICD-10 Code field to open the drop down list of available diagnosis codes.

If you are using ICD-9 codes, the process for entering them is the same. Utilize the ICD-9 Codes fields.

29

Select the applicable diagnosis code. The selected diagnosis code populates in the numbered fields below.

If you start typing in the field, the cursor will jump to the relevant location in the list of codes. If you manually enter the diagnosis code, you must press [Enter] after entering the code. Tabbing out of the field will not input or save the code.

If only one diagnosis code is entered, the save action ([Alt] + S) will auto-append the ICD-10 diagnosis link. (If multiple diagnosis codes are entered, the ICD-10 links will need to be added for each of the diagnosis codes in the next step.)

If the Enable ICD-9 to ICD-10 GEMs (General Equivalence Mappings) option is selected in Practice: [ID] > Miscellaneous tab, the GEM Scenario and Choice Selection window opens. Use this window to map the chosen ICD-9 code to the ICD-10 codes listed. Determine the appropriate Scenario, and then check the box next to a maximum of one code from each Choice List within that Scenario. You must press [Enter] after all ICD-10 codes have been selected in the dialog box.

If you need to edit a selected code, click Edit. The numbered code fields are now available to enter a new code. Delete one or more digits in the codes and the full diagnosis code list will display. Begin typing the new code to narrow the codes in the code list.

30

After all diagnosis codes have been entered for the CPT code, place the cursor in the ICD-10 Links field. The numbers of the corresponding code number fields appear, separated by commas.

Despite entering up to eight diagnosis codes, only four codes can be linked to the procedure code on claims. If the auto-populated codes are not correct, then edit them. It is not necessary to enter commas when entering the link numbers. The form will enter commas for you.

31

(Optional) Enter the quantity, as applicable to the selected procedure, in the Quantity field.

32

(Optional) Select the Hold Statement checkbox to hold guarantor statements at the procedure level.

Checking the box will single out this procedure and keep it from appearing on other statements sent to the guarantor. When you return to the Procedures & Provider Time tab and select the same procedure line, an indicator that the statement is being held at the procedure level displays.

33

(Optional) Enter the NDC for the procedure.

If entered, also specify:

The number of Units administered
The Quantity in each unit
The Price per Unit (Price/Unit)

The NDC is the National Drug Code for the drug administered by injection, as indicated by the J-Code procedure.

The NDC must be entered as 11 characters in the following format: #####-####-##, for example, 99999-5555-11.

34

(Optional) Enter an alternate description of the procedure, if the default description is not adequate, in the Override Procedure Description.

35

Click Save. The Add Procedure window closes. The procedure is now displayed in the Procedures list.

If you would like to enter an additional procedure, click Save & Add Next, which saves the form and clears it for entering your next procedure.

36

If the procedure is an anesthesia procedure, add the provider time in the Anesthesia Case Provider Time section by clicking Add Time (or press [Alt] + T). The Add Provider Time window opens.

37

Open the Provider Type drop down list and select the role the provider performed while administering anesthesia.

The first provider will be set as Directing. All other providers will be set as Directed or Observing.

38

Open the Provider drop down list and select the provider who performed the procedure.

39

Enter the date and time the procedure started in the Start Time field.

40

Enter the date and time the procedure ended in the End Time field.

41

To exclude the added time from concurrency validation checks, select the Exclude from Concurrency Checking checkbox.

Use caution when selecting the Exclude from Concurrency Checking option. If this option is selected, the case will not be validated for concurrency exceptions.

42

Click Save to continue. The Add Provider Time window closes.

If you would like to add additional provider time, click Save & Add Next, which saves the form and clears it for entering your next provider's time.

43

Open the Anesthesia Method drop down list and select the method used to administer the anesthesia.

44

(Optional) Enter the time at which the transition from a primary procedure to a secondary procedure occurred on the case in the Add-On Begin Time field.

This field is only available for add-on procedures.

45

Open the Physical Status field and select the option that indicates the physical condition of the patient.

46

To bill as a different provider than the one who performed the procedure, select the provider from the Override Bill As drop down list.

The selected provider will be listed on the claim rather than the one listed as the provider on the case.

47

(Optional) Select one or both of the following options when either of the conditions apply: