Overview
The Coding tab is used to code a case directly from an image set that contains case documents.
This tab includes the following areas:
- General Information
- Procedures
- Anesthesia Case Provider Time
The information entered on this tab is imported directly into a new case, which streamlines the charge entry process. This functionality works best with two monitors— one to view the image set and the other to code the case details from the image. If you are not using dual monitors, the image will appear behind the Coding [Set ID] tab.
Field Definitions
Field | Type | Required | Description | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Scale | Drop Down | Yes | The settings for magnifying the image or for adjusting the page magnification. By default, this option is set to Fit Page, indicating the image will be sized to the width and height of the page boundaries in the preview pane. To change the page magnification of the preview pane, click Fit Width to expand the image to the entire width of the preview pane. To magnify the image that is displayed in the preview pane, select a percentage from the list. You can magnify the image to 200% or reduce the image to 10%. If you use the IntelliMouse® mouse, you can use the wheel to change the magnification. To change the magnification using the IntelliMouse wheel, press and hold [Ctrl] while rotating the IntelliMouse wheel to the desired magnification. | ||||||||||||||
| Coding Status | System-calculated | Yes | The coding status of the image set: Not Coded, In Progress, On Hold, Ignored, and Complete. This status appears in the Coding Status column on the Charge Batches tab. By default, this option is set to Not Coded. Click the applicable status for the coding form. Only the forms that have a status of Complete can be imported into a case. | ||||||||||||||
| General Information Section | This section includes the information that will be imported into the patient, guarantor, and insurance information, general case information, and procedures. | ||||||||||||||||
| Patient | Free Text | No | The name of the patient who received services. By default, this option is blank. Type the patient name (Last, First, and Middle). The patient name is matched when the case is created using the information that you enter (first by last name, then by first name, and finally by middle name). For existing patients, all insurance information currently on record is also imported. If the patient cannot be matched by name, you can create a new patient while creating the case. | ||||||||||||||
| SSN | Free Text (numeric) | No | The nine-digit social security number of the person you are entering. By default, this field is blank. Type the social security number in the space provided. Do not enter dashes between values. If you do not have the social security number, leave this field blank. Do not use fictitious numbers, for example nines or zeros. The SSN is masked upon saving the form and cannot be unmasked and viewed from the tab. | ||||||||||||||
| DOB | Calendar Date (mm/dd/yyyy) | No | The patient's date of birth. By default, this date is blank. Type the date of birth in mm/dd/yyyy format or click the field to open the calendar control to select the date. | ||||||||||||||
| Date of Service | Calendar Date (mm/dd/yyyy) | No | The date the patient received the service. By default, this date is blank. Type or click the date of service. This information is required and must be entered before you can complete the procedures on the case. The date of service is imported into the Case: [ID] > General Case Information tab. | ||||||||||||||
| Admit Date | Calendar Date (mm/dd/yyyy) | No | The date the patient was admitted to the hospital. If the patient was admitted to a hospital, this dates is required. By default, this information is blank. If the patient was hospitalized, type or click the appropriate date from the calendar. Enter the date in mm/dd/yyyy format. | ||||||||||||||
| Discharge Date | Calendar Date (mm/dd/yyyy) | No | The date the patient was discharged from the hospital. If the patient was admitted to a hospital, this date is required. By default, this information is blank. If the patient was hospitalized, type or click the appropriate date from the calendar. Enter the date in mm/dd/yyyy format. | ||||||||||||||
| Charge Received | Calendar Date (mm/dd/yyyy) | No | The date recorded on the case for when the charge was received. | ||||||||||||||
| Facility | Drop Down | No | The healthcare facility where the patient was treated. By default, this option is blank unless the facility was specified in the EDC Interface Configuration and imported from the EDC file. Click the facility where the service was rendered. This information is imported into the general case information. | ||||||||||||||
| Referring Physician | Drop Down | No | The name of the referring physician, if applicable. By default, this option is blank. Open the dropdown option and click or type in the name of the referring provider. As an alternative to the dropdown box, you can also click the This information is imported into the general case information. | ||||||||||||||
| Facility Case ID | Free Text | No | The case number issued by the facility where the patient was treated. This field also houses the MRN number found on a charge ticket (for Charge Entry purposes). By default, this option is blank. Type the facility case number, if applicable. This information is imported into the general case information. If you are importing EDC files, the records in the EDC files are matched to the case by facility case number, external case number, or both. If you enter only the facility case number, the EDC file will use this number to match the records for the demographic download. If you enter both the facility case number and the external case number, both numbers must match the respective numbers in the EDC file. The records are in the EDC file is matched to the coded image set when the case is created from the image set. | ||||||||||||||
| External Case ID | Free Text | No | The identification number assigned to the case as an additional means of tracking the case. By default, this option is blank. Type the external case number, if applicable. This information is imported into the general case information. If you are importing EDC files, the records in the EDC files are matched to the case by facility case number, external case number or both. If you enter only the external case number, the EDC file will use this number to match the records for the demographic download. If you enter both the facility case number and the external case number, both numbers must match the respective numbers in the EDC file. The records are in the EDC file is matched to the coded image set when the case is created from the image set. | ||||||||||||||
| Emergency | Checkbox | No | The emergency indicator that specifies whether the patient was treated as a result of an emergency condition. By default, this option is blank (no emergency). Click this checkbox if the patient was treated as a result of an emergency. This information is imported into the general case information. | ||||||||||||||
| Box 19 | Free Text | No | The additional information to include in box 19 of the CMS 1500 claim form. By default, this information is blank. This option corresponds to the value set in Plan Claim Options and Paper Claim Options in the plan configuration. The information that you enter on the case overrides the value specified for the paper claim in the plan configuration. Type any additional information for the claim to appear in box 19 on the claim form. | ||||||||||||||
| Compensation Fee Schedule | Drop Down | No | The fee schedule for calculating compensation for your providers. This fee schedule is defined in the practice configuration. If your practice is not configured for compensation fee schedules, you do not see this option. By default, this option is blank. To specify a fee schedule, click the fee schedule from this list. If your practice has a custom compensation fee schedule, the Compensation Fee Schedule drop-down includes a list of available fee schedules. If your practice does not have a custom compensation fee schedule, this box is unavailable. | ||||||||||||||
| Practice | Read-only | No | The practice where the patient received services. | ||||||||||||||
| Procedures Section | This section includes the information to be imported into the Case: [ID] > General Case Information tab and Add Procedure or Update Procedure windows. You must first specify the date of service in the General Information area before selecting the procedure code (CPT). To ensure procedures are imported, the procedure must be included in the fee schedule. By default, additional procedures are populated with the provider and diagnosis codes (1–4) from the previous procedure. For example, the second and subsequent procedures are populated with the provider and diagnosis codes from the first procedure entered. You can override this information if needed. | ||||||||||||||||
| Type of Serv | Display Only (Pulled from added/updated Procedure) | Yes | The type of service provided. When the CPT code is any of the following, this value will be as indicated:
| ||||||||||||||
| Code | Display Only (Pulled from added/updated Procedure) | Yes | The procedure that was performed on the case. If the procedure can be mapped to an anesthesia code, the ASA column contains that anesthesia code. If procedure in the Code column is an anesthesia procedure, the ASA column contains that procedure code. | ||||||||||||||
| ASA | Display Only (Pulled from added/updated Procedure) | No | The corresponding anesthesia code of the procedure.
| ||||||||||||||
| Description | Read-only | Yes | The description of the procedure. This column contains information only and is updated when a procedure is selected in the Code column. | ||||||||||||||
| Modifiers | Display Only (Pulled from added/updated Procedure) | No | The two-character code used to describe the services associated with a procedure. A procedure can have up to four modifiers. | ||||||||||||||
| Diagnosis Codes | Display Only (Pulled from added/updated Procedure) | Yes | The diagnosis codes of the procedure. Each diagnosis code is represented in the priority of the relating diagnosis codes for the procedure. Diagnosis codes are ranked according to the primary diagnosis (1), secondary diagnosis (2), etc. | ||||||||||||||
| Qty | Display Only (Pulled from added/updated Procedure) | Yes | The number of units for the service being rendered, for example, the number of treatments. For an anesthesia procedure, this value is 1. | ||||||||||||||
| NDC | Display Only (Pulled from added/updated Procedure) | No | The National Drug Code of the drug administered by injection, as indicated by the J-Code procedure. | ||||||||||||||
| Provider | Display Only (Pulled from added/updated Procedure) | No | The name of the provider who performed the general procedure on the case. For an anesthesia procedure, this column is blank. Provider ID is required when the case includes a Directed CRNA. | ||||||||||||||
| Place of Serv | Display Only (Pulled from added/updated Procedure) | Yes | The designated place of service for the facility. | ||||||||||||||
| DOS | Display Only (Pulled from added/updated Procedure) | Yes | The date of service for the procedure. For anesthesia procedures, this column will be updated from the provider time after it has been recorded in the Anesthesia Case Provider Time section. The DOS column contains the actual date the service began. For anesthesia procedures that span more than one day, the DOS is calculated based on the date and end time recorded for the provider in Anesthesia Case Provider Time and will be reported in the 837 at the service line level. | ||||||||||||||
| Anesthesia Case Provider Time Section | |||||||||||||||||
| Provider Role | Display Only (pulled from Provider Type field on Add Provider Time window) | Yes | The role the provider performed while administering anesthesia: Directing, Directed, or Observing. | ||||||||||||||
| Provider Name | Display Only (pulled from Provider fieldon Add Provider Time window) | Yes | The last, first, and title of the provider who performed the anesthesia procedure specified. | ||||||||||||||
| Start Time | Display Only (pulled from Start Time field on Add Provider Time window) | Yes | The date and time the provider started the anesthesia procedure as specified. The provider time can span days within a time range for an individual provider. For example, a procedure started on 09-14-2014 at 19:00 and ended on 09-15-2014 at 00:52 for a solo provider. This time can be entered as one start and end time entry as 09-14-2014 19:00 (start time) and 09-15-2014 00:52 (end time). If the procedure includes an add-on procedure (for example, 01967 and 01968), the time can be entered as a single entry with the start time for the add-on procedure entered in the Add-On Begin Time field. | ||||||||||||||
| End Time | Display Only (pulled from End Time field on Add Provider Time window) | Yes | The date and time the provider ended the anesthesia procedure as specified. The provider time can span days within a time range for an individual provider. For example, a procedure started on 09-14-2014 at 19:00 and ended on 09-15-2014 at 00:52 for a solo provider. This time can be entered as one start and end time entry as 09-14-2014 19:00 (start time) and 09-15-2014 00:52 (end time). If the procedure includes an add-on procedure (for example, 01967 and 01968), the time can be entered as a single entry with the start time for the add-on procedure entered in the Add-On Begin Time field. | ||||||||||||||
| Exclude | Display Only (pulled from checkbox on Add Provider Time window) | No | To exclude the time segment from concurrency checking, the Exclude from Concurrency Checking checkbox is selected in the Add Provider Time window when adding time. If selected, the Exclude column is checked. This differs from the Exclude from Concurrency Checking option to the right of the table, which excludes the entire case from concurrency checking validation. | ||||||||||||||
| Anesthesia Method | Drop Down | Yes | The method used to administer the anesthesia. The options include::
If you change the Physical Status field value, the data displayed in the PSUs column under Procedure Detailswill be updated, which might cause the fees to be recalculated.
When rebilling a service line item without fee changes, you cannot change this value. | ||||||||||||||
| Add-On Begin Time | Calendar Date and Time (mm/dd/yyyy hh:mm) | No | The time at which the transition from a primary procedure to a secondary procedure occurred on the case, if applicable. For example, suppose the primary procedure started as anesthesia for a vaginal delivery, but then evolved into a secondary procedure as anesthesia for a C-section. In this case, you would enter the start time of the secondary procedure, which is the anesthesia related to the C-section. The Add-On Begin Time option is only available when procedures 01968 and 01969 are entered in the procedure details table. The primary procedure and the add-on procedure must be entered in the procedure details table. In addition, both the primary procedure and the add-on procedure must be included in the current billing fee schedule. If either 01968 or 01969 procedure (anesthesia add-on procedure) is included in the procedure details table, the add-on begin time is required. By default, this information is blank. | ||||||||||||||
| Physical Status | Drop Down | Yes | The billing unit value added to an anesthesia procedure to indicate the complexity of the procedure regarding the physical status of the patient. The billing unit values are used to calculate anesthesia fees. The supported physical status modifiers are P1 through P6. This information is required if the procedure is an anesthesia procedure. By default, this option is blank. Select a value from P1 to P6 for the physical condition of the patient. The following table contains the description of each modifier according to the American Society of Anesthesiologists (ASA) ranking of patient physical status:
| ||||||||||||||
| Override Bill As | Drop Down | No | The option for overriding the billing provider to bill as a different provider than the one who performed the anesthesia procedure. For example, the physician instead of the CRNA who actually performed the anesthesia procedure. By default, this information is blank. To bill as a different provider, choose the provider from the list. The provider you choose will be listed on the claim instead of the provider who performed the service. | ||||||||||||||
| Exclude from Concurrency Checking | Checkbox | No | Indicates if the case will not be validated for concurrency exceptions. This option is specific to anesthesia and can only be selected if the procedure includes anesthesia. Use caution when selecting this option as concurrency exceptions will not be reported, which could result in fraudulent billing. By default, this option is blank. To exclude the case from concurrency validation, click the checkbox. If you click this option, the following message appears: Excluding this case from concurrency checking may result in fraudulent billing. Click No to close the message without activating this option. Click Yes to stop concurrency validation on this case. When rebilling a service line item without fee changes, you cannot change this value. | ||||||||||||||
| Force Team Supervision | Checkbox | No | Indicates that not all medical supervision conditions might have been met for medical direction on the case. The case will be billed as medical supervision. At least one Directing provider and one Directed provider must be specified in the Anesthesia Case Provider Time section. Not following the medical direction criteria may result in an audit. By default, this option is blank. Click this option to apply the supervising modifier on the case. If you click this option, the following message appears: Enabling team supervision will cause the case to be billed as medical supervision. This indicates that not all medical supervision conditions have not been met for medical direction. Click No to close the message without activating this option. Click Yes to apply the supervising modifier to this case. When rebilling a service line item without fee changes, you cannot change this value. |
Button Descriptions
Button | Shortcut Keys | Description | Step-By-Step Guides |
|---|---|---|---|
| Procedures Section | |||
| Add | [Alt] + [A] | To add a procedure. | See Steps 44-60 |
| Update | [Alt] + [U] | To modify a procedure. | See Steps 44-59 |
| Remove | [Alt] + [R] | To delete a procedure. |
The procedure is deleted unless one or more of the following conditions apply:
|
| Override | [Alt] + [O] | To apply override values to a procedure. | See Step 44 Additional Information |
| Anesthesia Case Provider Time Section | |||
| Add Time | [Alt] + [T] | To record provider time on an anesthesia procedure. | See Steps 61-73 |
| Update | [Alt] + [P] | To modify provider time. | See Steps 60-71 |
| Remove | [Alt] + [E] | To delete provider time. |
|
| Edit Note | [Alt] + [D] | To add a note to the coded information. |
|
