Adding an Encounter

Adding an Encounter

You can add the following Encounter Types:

• Evaluation
• Treatment
• DME
• Medical Records Fee
• Supply/ Retail Item

Adding an Evaluation, Treatment, or DME Encounter:

• Open the patient's case
• Go to the Account tab
• Double check that the Treatments/ DME tab under the Encounters header is Blue

**Note: Medical Records Fee and Supply/ Retail Item Encounters should be added under the Medical Records/ Retail Supply tab of the Account tab (Explained below in 'Adding a Medical Records Fee or Supply/ Retail Item Encounter')

• Click on the Add Encounter button above the Encounters header

• You'll then see the Add an Encounter pop up window

• Enter the Encounter Date (The date will auto populate as the current date, please be sure to change this if the Encounter Date/ Date of Service should be something different)
• Enter the Encounter Location (The location will auto populate as the location of the patient's case)
• Select the Encounter Type of Evaluation, Treatment, or DME
• Click Save & Add Encounter
• You'll be pulled into the Evaluation, Treatment, or DME Encounter you just created to add charges

Adding charges to the New Encounter

• Enter the Charge/ CPT code in the New Charges section of the Account tab

• Start typing the Charge/ CPT code in the Charge -Select- drop-down menu

• Click on the Charge/ CPT code you'd like to add
• You'll then see the code populate in the New Charges section

• Verify the following: 
  • That the correct Charge/ CPT is selected
  • Associated Diagnosis codes 
  • Number of units to bill
  • If this is being billed to insurance or if this will be a Self Pay charge
  • Apply a Modifier to the CPT code if necessary

To Remove a Diagnosis code: 

• Click the X to the right of the Diagnosis in the Diagnosis box

To Add a Diagnosis code:

• Click the + next to the Diagnosis field

• You'll then see the Select Code for Additional Diagnosis pop up window

• Start typing a Diagnosis code or Chief Complaint in the Keyword Search box

• You'll then see the coding section that the requested Diagnosis falls under. 

• Click the arrow to the left of the coding section to expand the sections until you get to the most specific diagnosis that matches your search. This will be listed in Blue. 

• Click on the Blue code 
• You'll then see an Instructional Notes section pop up to the right

• Click on Use This Code to add it to the Diagnosis list for the Charge/ CPT code

• You'll then see that Diagnosis added to the listed Diagnoses for that Charge/ CPT code

• Enter the Number of Units that need to be billed for this Charge/ CPT code

• Click the Self-Pay checkbox if the patient is going to be Self-Pay for this treatment

• Enter the applicable Modifier if necessary for that Charge/ CPT code in the Modifier field

• You can modify anything entered if needed until you click Submit
• If you realize you made an error and want to delete ALL the information, click the Trash Can icon

• Click Submit to add the Charge/ CPT code to the Evaluation Encounter 

• You'll then see the charge for Treatment added to the Encounter under the Charges Summary section of the Account tab

Adding an Medical Records, Retail Supply Encounter:

• Open the patient's case
• Go to the Account tab
• Double check that the Medical Records/ Retail Supply tab under the Encounters header is Blue

**Note: Evaluation, Treatment, and DME Encounters should be added under the Treatments/ DME tab of the Account tab (Explained above in 'Adding a Evaluation, Treatment, or DME Encounter')

• Click on the Add Encounter button above the Encounters header

• You'll then see the Add an Encounter pop up window

• Enter the Encounter Date (The date will auto populate as the current date, please be sure to change this if the Encounter Date/ Date of Service should be something different)
• Enter the Encounter Location (The location will auto populate as the location of the patient's case)
• Select the Encounter Type of Medical Records Fee or Supply/ Retail Item
• Click Save & Add Encounter
• You'll be pulled into the Medical Records Fee or Supply/ Retail Item Encounter you just created to add charges

Adding charges to the New Encounter

• Enter the Charge/ CPT code in the New Charges section of the Account tab
  • Each Supply should have a specified Charge/ CPT code
  • Medical Records Fee Charge/ CPT code is Medrec Fee

• Start typing the Charge/ CPT code in the Charge -Select- drop-down menu

• Click on the Charge/ CPT code you'd like to add

• You'll then see the code populate in the New Charges section

• Choose the Requestor/ Payer from the drop-down menu 
  • For Self Pay Supplies/ Retail Items- Search & Select the Guarantor from the drop-down
  • You can also select the patient's insurance plan if this is a billable supply code

• Enter the quantity of the Supply/ Retail Item

• Enter Notes in the Notes field

• Click the Trash Can icon to remove the entry created so far

• You can modify anything entered if needed until you click Submit

• Click Submit to add the Medical Records Fee or Supply/ Retail Item to the Encounter 

• You'll then see the charge for Medical Records or Supply/ Retail Item added to the Encounter under the Charges Summary section of the Account tab

**Note: You will be able to remove the added transaction while the status is 'created'. Once the status flips to billed you will no longer be able to remove the charge

• To Remove the charge after it's been added to the Encounter: 
  • Click the Trash Can icon under the Charges Summary section