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EMR & EDR Element - Diagnoses & Billing

The Diagnoses & Billing Element replaces the Care Slip Element.
Note: Any information that may have existed in the Care Slip Element in MacPractice previously for a given patient, will now appear in this element under Past Diagnoses and Problems, as will entries from the patient's Problem List, and their diagnosis history on the current incident.

It should be noted that since this element keeps track of both diagnoses and billing information, it is larger than many other elements.



Encounter Diagnoses
Clicking the green plus in the top right corner of Encounter Diagnosis will bring up the Universal Coding View. If you are looking for a diagnosis code that had previously been saved to your care slip reference, those are available in this window within the Care Slip tab. Once the proper diagnosis has been selected, it will appear in the element.


If the Diagnosis needs to be moved to the problem list in the Patient’s Clinical Tab, it can be done by clicking the Add Problem button next to the diagnosis. Alternatively, if a Diagnosis from the element was accidentally added, the text in on the button is adjusted to say Undo Add. Clicking Undo Add will remove the Diagnosis from the Problem List.

The list of Diagnoses may be rearranged by dragging and dropping the diagnoses to their desired position.

Past Diagnoses and Problems
This is a record of any Diagnoses that exist in the Patient’s problem list. This also contains any diagnosis that may have existed in the Care Slip Element from previous versions of MacPractice.

The arrow to the left will allow a Past Diagnosis to be placed in the Encounter Diagnoses list. If a Past Diagnosis was moved to Encounter and it should be moved out, a down arrow will appear next to the Diagnosis that will remove it from the Encounter list.

The Move All to Encounter Diagnoses button will move every listed Past Diagnoses into Encounter Diagnoses.


Procedures
This is where Procedures that should be assigned with the Diagnoses should be entered.


Clicking the green plus will bring up a window that allows the entry of billing codes. Procedures that were previously tied to your care slip reference will populate this window by default; other procedures can be searched for as well. Multiple codes may be added to the Procedures list.


The Review and Bill button brings up another window. This window works similarly to the New Charge Window in the Ledger. This will create an order for the biller to add charges to the patient’s ledger.


Across the top of the window, the Assign Order To is a drop down list with a selector for which user should have the order assigned.

The next two checkboxes ensure that the same Date or the same Diagnosis should be used for All Procedures listed.

Procedures is a list of all of the procedures added into the element. When one of these are selected, on the right you will see a break down of the Procedure. If the Date needs to be changed, it can be changed here, as well as other details such as Units, Tooth Surface, etc. as necessary.

Diagnosis is the box that allows the selection of specific diagnoses (that have been added through the element) to be applied to a specific Procedure (if the Same Diagnosis checkbox has not been selected).

Notes is a text field that will translate to the Procedure Notes for a claim.

Clicking Create Order will generate an Order in MacPractice.
Note: Creating an Order does not put billing information directly into a patient’s ledger.

The Show Orders button in the Diagnoses & Billing Element shows any Orders that have been generated with information from the element.


The checkbox to the right, when checked, shows the Order on the patient’s narrative. If an order has been changed or submitted by mistake, unchecking this box removes the order from the narrative.

Resizing the Element and the Section
The Diagnoses & Billing element is larger than most elements. Since this replaces the Care Slip element, any EMR/EDR form that utilized Care Slip will now use Diagnoses & Billing, but the section containing that element will need to be resized to display the full details.

To resize the section, select it from the Form Sections list in the sidebar and open the Form Section Palette. Diagnoses & Billing takes up the full page, so the Height will need to be set to its maximum of at least 650. If the height is less than 650, the element will not display all of the information. The height can go up to 792.


Once the height of the section has been changed, you may also need to reposition the element within the section. To do so, simply click and hold on the element, and drag it into position.
Note: If the Height cannot be changed, the Locked checkbox must be unchecked.

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