Enter Procedure Codes
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Procedure codes (E/M, CPT and HCPCS) capture the level and complexity of care provided to the patient during the visit. Procedure codes are mapped to diagnosis codes.
Navigate to Patient Chart / Notes
- Enter the first 2–3 letters of the patient's name in the top navigation bar search box.
- Click to select the patient from the auto-populated results. The patient's chart / Face Sheet opens.
- Click Notes on the left menu. The Notes page opens.
- Click Open on the right of the note for which you want to generate a Superbill. The note opens.
Open a Superbill
- Click Superbill on the bottom task bar of the clinical note. The Superbill Coding window opens.
Enter Procedure Codes
Enter the information in the Procedure Code section of the Superbill - Coding window.
- Enter the first 3 numbers of the code or first 3 letters of the name. Select the procedure code from the auto-populated results. The code is added to the list.
- Codes can also be searched using the Browse function. Click Browse and the Procedures Browser window opens.
- Favorites: Provides a list of the codes you frequently use.
- Custom: If you are integrated with Kareo's Desktop Application (PM), you can access custom procedure codes and modifiers that were created in the PM.
- Search: Look up by code or name. For example, enter a problem in the search field and click Search. Click x to clear the entry for a new search.
- Qty: Enter the quantity delivered to the patient as appropriate (maximum of four characters exclusive of a decimal point).
- Modifiers: Enter up to four applicable modifiers.
- Calculate E/M: Click to access a time-saving E/M calculator that provides the appropriate code level based on provider input. The E/M code is then added directly to the superbill and increases billing accuracy. (See section below.)
- Mapped Diagnosis: Diagnosis Codes are mapped to Procedure Codes in the order in which they appear in the ICD section. Click the drop-down arrow to select up to four Diagnosis Codes for the Procedure Code.
- Click and drag a code to adjust the Rank, if necessary. If you have entered multiple procedure codes, you may need to reorder them to satisfy insurance requirements and to properly map to their associated diagnosis codes.
- Click x to delete the Procedure Code, if necessary.
- To access E/M Assistance, click Calculate E/M. The E/M Assistance window opens.
- When using the calculator, refer to the guidelines for Evaluation and Management Services as established by the Centers for Medicare & Medicaid Services. Choose one of two guidelines (not both): “1995 Documentation Guidelines for Evaluation and Management Services” or “1997 Documentation Guidelines for Evaluation and Management Services.”