ExamWRITER User. Day One Agenda. Day Two Agenda. Page 1

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1 ExamWRITER User Day One Agenda 8:15 AM 8:30 AM Continental Breakfast 8:30 AM 9:00 AM Meet and Greet 9:00 AM 10:00 AM EMR Challenges Open Forum 10:00 AM 12:00 PM Template Building for Increased Efficiency 12:00 PM 1:00 PM Lunch and Networking 1:00 PM 2:00 PM Menu Editor: Have It Your Way 2:00 PM 3:00 PM The Magic of the HPI Wizard 3:00 PM 3:15 PM Break 3:15 PM 5:00 PM Patient History: Providing a Firm Foundation Day Two Agenda 8:15 AM 8:30 AM Continental Breakfast 8:30 AM 9:00 AM Meet and Greet 9:00 AM 10:00 AM Before You Enter the Room: Patient History Review 10:00 AM 12:00 PM Documenting Pathology 12:00 PM 1:00 PM Lunch and Networking 1:00 PM 2:00 PM Nuts and Bolts of Eyeglasses and Contact Lens Documentation 2:00 PM 3:00 PM Completing the Exam Page 1

2 EMR Challenges Open Forum What challenges, if any, have you faced or do you think you may face using ExamWRITER? Have you encountered an item you could not locate in ExamWRITER? Do you have a unique solution you would like to share? Page 2

3 Template Building for Increased Efficiency Template Formats Narrative lists information in a paragraph form Line Item lists information line by line. Templates can be built in a narrative format, a line item format, or a combination of the two formats. Creating a New Template 1. Click Tools and select Template Maintenance. 2. Click New. 3. Type the name of the template and click Save/Exit. The exam record opens with the name of the template appearing at the top. Click to enter each category bar to build the template with the desired information. Templates can be built in a narrative format, a line item format, or a combination of the two formats. Editing an Existing Template 1. Click Tools and select Template Maintenance. 2. Highlight the template of your choice and click Edit. The template opens and clearly says: Template Maintenance. Enter each category where changes are to be made. Remember: click to open each category, and in most cases, right click to delete existing text. Copying Template Information It is possible to copy from a template that has already been created. 1. Highlight the name of the template to be copied. 2. Click New and type a new name. The New button becomes the Copy From button. Page 3

4 3. Click Copy From and when the confirmation dialog box appears, click Yes. Template Tips and Tricks Use Unknown in both Primary Care Physician and Other Physician. Create Customized Notes for Lifestyle or Dry Eye Questionnaires. Use a period (.) as a placeholder. Using Click Here or right-click to delete as a guide for technicians. Create a template for telephone calls. Change the order of the exam items in Menu Editor. Change the exam description in Menu Editor. Name the templates by the exam type. Comprehensive with CTL Fit Template Telephone Call Template Page 4

5 Comprehensive Exam with CTL Fit Page 5

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7 Menu Editor: Have It Your Way 1. On the ExamWRITER main window, click Tools and select Menu Editor. The ExamWRITER Editor window opens. 2. Select the category in which you want to customize Exam Data and Auto Letter Sequences. Page 7

8 3. Modify the sequence of exams and auto letters using the arrow buttons on the right side of the Exam Display and Exam Report Sequence box and Auto Letter Sequence box. 4. Select the Red check boxes in the Exam Display and Exam Report Sequence box to display subcategories in red text on the ExamWRITER chart window. Page 8

9 Items selected appear in the correct sequence and in the colors selected. 5. Click Text Editor to customize descriptive exam text. The ExamWRITER Text Editor window opens. 6. Double-click a subcategory to customize the exam text within the category. Page 9

10 7. Select the checkbox prompt. 8. To change the User s Text, click the line item and type the desired text. Data appears in the exam record as it was recorded in Menu Editor. Page 10

11 The Magic of the HPI Wizard Medicare s definition of the History of Present Illness (HPI): The HPI is a chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present. The eight elements of the HPI: Location Severity Quality Timing Duration Context Modifying Factors Associated Signs & Symptoms When billing 99 codes, there must be a minimum of four elements documented when billing higher than a The HPI Wizard makes the job of documenting complaints worry free. 1. To turn on the HPI Wizard, click Tools and select Preferences. Page 11

12 2. On the General tab, select Use HPI wizard and Show HPI in line item format check box. 3. Now, when you click the HPI category bar during an exam, select the Common Ocular Complaints check box. Selecting the Common Ocular Complaints check box opens the HPI Wizard. Page 12

13 4. Search for and select a complaint in the box on the left side of the window (press the F12 key to add a complaint to the box). 5. In the Keyword and Long Description text boxes, left-click to select the appropriate items from the drop-down menu list and then right-click to save your selections. 6. To modify or add keywords and long descriptions, left-click in a Keyword text box and press the F12 key. 7. Click Save Item to add the complaint to the Ocular Complaint table at the bottom of the window. To edit a saved complaint, click Edit and modify the text. To delete all complaints, click Delete All; or, to delete one complaint, select it and click Delete Item. 8. After you have finished documenting all ocular complaints, click Process to save your selections. Page 13

14 Patient History: Providing a Firm Foundation The Patient Quick List appears on the right side of the main ExamWRITER window. Note: If the Quick List does not appear on the main window, click Tools and select Show Patient Quick List. If the Quick List does not automatically open when ExamWRITER starts, select the Display Quick List at Startup radio button on the System Preferences window. If the office is using the OfficeMate Appointment Scheduler, the Patient Quick List provides a list of all patients with scheduled appointments. 1. Left click and highlight a name from the list, then right click for three additional options. Update Patient Room Opens a room list. Each office creates a list of rooms specific for their office. New Exam Records the patient name directly on the ExamWRITER Control Center. Patient History Opens the Patient Information Center Hx tab. Page 14

15 2. Select New Exam. The patient s name is copied into the control center, if there have been any records created electronically, they will appear in the Previous Exam section. 3. Verify information regarding the patient in the Patient Information section, including any Notes or Alerts. 4. If needed, make corrections to the Exam Information in the Provider and Exam Date drop down menus. Page 15

16 5. Open the exam record by clicking the New Exam button and select to Create a New Blank Exam or use an Available Template. 6. From within a previous exam, there is an option to use the Copy Forward feature. The exam record will open and each category line will clearly show the original exam date and will need to be updated. Page 16

17 7. When using the Copy Forward feature, simply change any documentation that is different from the previous examination. The information that will be copied forward is determined in Preferences. Reason for Visit Physician Database Click the column header to sort the physician database. If you click on the Full Name column header the doctors names will be ordered by first name. Tip: By placing the first letter of the last name in the File As column, you can order the doctors by last name. If you want to know the type of doctor, place a dash (-) after the first letter of the last name and add the type of doctor, (e.g., ophthalmologist, PCP, etc.) The Search File As for field allows you to search by the first letter of the last name. Page 17

18 Tip: Creating a doctor Unknown in the template prompts the staff to enter the name of the PCP. If the patient does not have a PCP or does not know the name of the PCP, simply leave the field to read Unknown; otherwise click on Primary Care Physician and replace Unknown with the name of the PCP. Technician Name Tip: Prior to creating your template, enter a staff member named Technician Name in Setup>Business Names>Provider/Staff. Select the No radio button beside Provider. Page 18

19 When creating the template, use Technician Name in the Exam Technician Name drop-down menu. This will remind the staff to select their name from the drop-down menu to enter it in the medical record. Page 19

20 Notes The notes section of Reason for Visit can be used two different ways: Custom-text. Use F12 to create notes that will be used frequently. Left-click to highlight and right-click to insert. Occupation, Last Exams and Lab Orders Occupation pulls forward from the Occupation field in Patient Demographics. Last Exam Date pulls from the last exam entered in ExamWRITER. Lab Orders allows you to monitor the last lab order, along with the date the order was created and the date the order was dispensed. Chief Complaint When you are ready to document the elements, selections will be made from the programmed menu. You can also use Custom Text option to record a specific patient response. To add to the Chief Complaint options, choose F12. Tip: Number the most commonly used chief complaints in the Description column and select the A-Z button. This will place the most common complaints at the top of the list. Page 20

21 History of Present Illness (HPI) You can turn the HPI Wizard on or off in the Preferences window. If you use the HPI Wizard, the category bar will open with the menu listing the common ocular complaints as one selection. Note: The HPI Wizard has been previously covered in this course. We will now cover how to document the HPI if you chose not to use the HPI wizard. If you do not use the HPI Wizard, you can choose the All OK Statement for a narrative format, or you can select 4 of the items and describe them as normal for a line item format. See examples below: Example #1: All OK (Narrative) Page 21

22 Example #2: Choose four elements (Line item) Note: When billing a 99203, 99204, or 99305, Medicare requires 4 elements of the HPI. Patient History Like the HPI, the Patient History may be used with the All OK statement, or you can list each part of the history as normal in line item format as seen in the example below: Note: When billing or on a New Patient, Medicare requires 3 elements of the HPI. Page 22

23 ExamWRITER always carries forward previously entered Patient History. Review of Systems Example #1: Narrative Example #2: Line Item Example #3 Note: A level 5 ROS requires documentation of 10 + elements. Page 23

24 Before You Enter the Room: Patient History Review When using paper charts, it is common for the doctor to look over the chart briefly prior to entering the room to see the patient. By selecting the Patient Hx button ExamWRITER provides a snapshot of the patient s history, including: Patient Demographics Notes/Alerts Diagnosis Procedures Exam History Family members Blood pressure/pulse (with graph) Pachymetry (with graph) CD ratio (with graph) Intraocular pressure (with graph) Medication History Current Therapeutic Rx Medical History Surgical History Ocular History Ocular Surgical History Spectacle Rx: Presenting, Auto Refraction, Manifest, Cycloplegic, Final and Alternate Contact Lens Rx: Presenting, Trial, Sph-Cyl ORx, Sph Orx, Final Page 24

25 1. To view the patient history, click the Patient Hx icon in the ExamWRITER Control Center. 2. If you are already in the medical record, you can access the patient history by selecting the Patient Hx icon in the tool bar. Another way to access the patient history is by clicking on the yellow Hx button within the medical record. Page 25

26 Documenting Pathology E&M Documentation Guidelines Reason for visit should be directly stated Reason for test should be directly stated or easily implied HPI performed by physician for 99XXX visits History and records review documentation Medical necessity criterion met Order for tests documented Interpretation and Report documentation Routine ophthalmoscopy findings should be separately identifiable Signature electronic Billing ICD s and CPT s need to be reflected in documentation Medical Necessity Reason for diagnostic test? Directly stated or easily implied Will it affect diagnosis or treatment? PQRI Measures To set up OfficeMate to participate in the Physician Quality Reporting Initiative (PQRI), you must first designate the PQRI diagnosis codes and then designate the Level II procedure codes. To set up PQRI reporting, perform the following steps: 1. Designate the Qualifying Diagnosis Codes a. From the OfficeMate main window, click Setup. b. Select Customization. c. Click the Diagnosis Codes tab. d. Select the diagnosis code from the list on the left. e. Select the PQRI (Voluntary) check box. f. Repeat steps 4 and 5 for each qualifying diagnosis code. g. Click OK when you are finished. Page 26

27 2. Designate the Level II Procedure Codes Note: Before you can record the new level II procedure codes on fee slips, you must create new services to which you want to link the new level II procedure codes in the Products window and select the appropriate new level II procedure code from the CPT/HCPCS Code drop-down menu. For information on creating new services, refer to the "Maintaining Product & Service Information" chapter of the OfficeMate User's Guide. The following new procedure codes have been added to OfficeMate for use with PQRI: 2027F, 4007F, 2019F, 1055F, 3073F, 2020F, 2021F, 5010F, 2022F, 2024F, 2026F, and 3072F. a. From the Customization window, select the Procedure Codes tab. b. Select the procedure code from the list on the left. c. Select the Level II CPT Codes check box. d. Repeat steps 2 and 3 for each qualifying procedure code. e. Click OK when you are finished. When you use a PQRI diagnosis code on a fee slip, also include a Level II CPT code. If you would like OfficeMate to remind you to select the Level II CPT code, perform the following steps: a. From the OfficeMate main window, click Setup. b. Select Preferences. c. Click the Other tab. d. Select the Yes radio button for Display reminder for level II codes. e. Click OK when you are finished. Page 27

28 Surgery & Special Testing Special Testing-Interpretation & Reports o o o Divided into ophthalmic, other test, and lab Ophthalmic are special ophthalmological tests and code with level I CPT codes Other are screening and misc. tests and code with S9986 codes as indicated or no codes when included in exam Surgery-Operative notes o Auto code CPT; use modifiers as indicated Auto coding with ExamWRITER CPT auto code o o o o ICD auto code o o Patient Management ExamDRAW Unilateral codes auto code with RT, -LT Screening codes auto code with S9986 Can add modifiers as needed Add exam CPT or refraction to template for auto coding Auto code from impressions ICD order can be changed for top 4 billing to CMS claim form Counseling/education documentation Eyemaginations Attending Attestation Electronic signature Current and Future Orders 1. Click the ExamDRAW icon. 2. Use the radio buttons to select an area to draw. 3. Click Continue. 4. Create a drawing to document any portion of the eye in each of the eight tabbed areas. Page 28

29 Within each tabbed area, you can record specific conditions and measurements. The Auto Text tab records the condition and location. The Comment tab allows you to manually record information. Patient Report & Auto Letter Scenario 1 Scenario 2 Patient report generation of impressions, plan and special testing items. Auto Letter facility Can be modified and annotated in Word Can , efax, or print for patient. Encounter documentation of patient presenting for wellness exam and glasses. You find a corneal foreign body that needs removal You find cupping that needs special testing Diabetic presenting with transient refraction change Page 29

30 Nuts and Bolts of Eyeglasses and Contact Lens Documentation To record and modify the Presenting Spectacle Rx: 1. Click in the Presenting Spectacle Rx box in the top middle of the Vision/Rx ExamWRITER chart window. OR Click the Presenting tab on the Rx window. 2. Click the blue slider bar or the measurement buttons to add measurements to the Spectacle Presenting OD, OS, and OU text boxes. OR Type the appropriate measurements in the Spectacle Presenting OD, OS, and OU text boxes. 3. If the patient has a nonprescription underlying condition, select Balance Lens, No Lens, Not Recorded, or Prosthesis from the Underlying Conditions drop-down menu. 4. Select the prescription s usage from the Usage drop-down menu. Use the F12 key to modify the Usage window. 5. Click the BPD or MPD radio button and then click your cursor in a Dist or Near text box to open the Pupillary Distance window and record the pupillary distance measurements. 6. If you want to copy the presenting prescription to the subjective manifest prescription, click Copy to Manifest. Shortcut for entering presenting spectacles 1. Select the yellow Hx button in the Presenting Spectacle area. The Rx History will be displayed. Page 30

31 2. Right-click any past Rx and select Copy to Primary Presenting, Copy to New Presenting, Copy to Manifest, or Copy to Cycloplegic. 3. To enter a second pair of Presenting Spectacles, click New Rx and choose an option from the Usage box, (e.g., Sunglasses). 4. Click the yellow Observation button to document the type of lens (e.g., Bifocal, Trifocal, Progressive), Add Item and Save/Exit. To add the Auto-Refraction, Retinoscopy, Manifest, and Cycloplegic, use the same basic steps as entering the Presenting Spectacle Rx. Page 31

32 To record and modify the Final Spectacle Rx 1. Click in the Final Spectacle Rx box in the bottom left of the Vision/Rx chart window. OR Click the Final tab on the Rx window. 2. Click the blue slider bar or the measurement buttons to add or edit measurements to the Spectacle Final OD, OS, and OU and text boxes. OR Type the appropriate measurements in the Spectacle Final OD, OS, and OU text boxes. 3. If the patient has a nonprescription underlying condition, select Balance Lens, No Lens, Not Recorded, or Prosthesis from the Underlying Conditions drop-down menu. 4. Select the prescription s usage from the Usage drop-down menu. 5. Select the prescription and expiration dates from the Prescription Date and Expiration Date drop-down menus. 6. Choose the Lenses and Add-on options. 7. Select the Create Lab order button to transfer the order to the optician. 8. Save/Exit. Page 32

33 Note: you may use the Alternate Spec. Rx field to record other final Rxs. To record and modify the Presenting Contact Lens Rx: 1. Click in the Presenting Contact Rx box in the top left of the Vision/Rx chart window. OR Click the Presenting tab on the Contact Lens Rx window 2. Click the blue slider bar or the measurement buttons to add measurements to the Contact Lens Rx Presenting OD, OS, and OU text boxes. OR Type the appropriate measurements in the Contact Lens Presenting OD, OS, and OU text boxes. Page 33

34 3. Click the ellipse (...) next to the OD and OS Product Name boxes to select contact lens product names. The Select Contact Lens window opens. 3. Select the appropriate product name, click Search to search for a specific product with the measurements you recorded (if applicable), and double-click the appropriate product details line in the bottom part of the window to add the contact lens product name, tint, and lens (if applicable) to the presenting contact lens prescription. OR Select the appropriate product name and click Product Name only to add only the product name to the presenting contact lens prescription. 4. Chose other applicable selections, such as tint, dot, and near eye if fitting monovision contacts. 5. If you want to add presenting contact lens prescription impressions and observations to the EMR, click Observations. Page 34

35 6. The Presenting CL Rx Impressions/Observations window opens. 7. Select the appropriate check boxes and click ADD Item(s). 8. Click Save/Exit. Note: The steps for selecting Trial Lenses and Final Contact Lenses are very similar to the steps used for Presenting Contact Lens. Page 35

36 Completing the Exam When the exam has been completed, the next step is Coding the exam. Using Quick Code Use ExamWRITER s Quick Code function to accurately and automatically determine the level of medical code documentation (based on the Evaluation and Management Services Guide by the Centers for Medicare & Medicaid Services (CMS)) needed for billing purposes on new exams. The check box selections that you record in a patient s exam record that relate to 99xxx procedure codes are tallied and recorded in the Documented Elements row on the E&M Quick Code Check window. 1. Click the Quick Code icon in the top left of the ExamWRITER chart window. The E&M Quick Code Check window opens. 2. Note the appropriate code for billing purposes. The lowest level of code that you have selected (as denoted by blue boxes) is what you are able to bill a patient. To meet CMS guidelines, you cannot bill a level 5 E&M code unless all of the boxes in the level 5 row are blue. For example, if there is a blue HPI box in the level 2 row and blue ROS, PFSH, Phys Exam, Diag/Mgmt, and Risk boxes in the level 5 row, you must bill the level 2 E&M code unless you document additional HPI elements to create a blue HPI box in the level 5 row. 3. If an insufficient number of elements were documented in the exam, click the heading of the insufficient aspect to go to the insufficient portion of the exam and add the necessary information. Page 36

37 Selecting Diagnosis Codes 1. Click the Coding icon in the top left of the ExamWRITER chart window. The Diagnosis/Procedure Coding window opens. 2. Click the Diagnosis tab. Note: The diagnosis codes are automatically displayed in the Selected Diagnosis table for the impressions that you recorded in the exam. 3. Double-click diagnosis codes to add them to the Selected Diagnosis table. OR Click Auto Code to automatically populate the Selected Diagnosis table. Selecting Procedure Codes 1. Click the Coding icon in the top left of the ExamWRITER chart window. The Diagnosis/Procedure Coding window opens. 2. Click the Procedures tab. The procedure codes are automatically displayed in the Selected Procedures table based on your exam selections. 3. Double-click procedure codes to add them to the Selected Procedures table. OR Click Auto Code to automatically populate the Selected Procedures table. Page 37

38 4. Click the arrows to the left of the table to rearrange or delete the codes in the Selected Procedures table. You can move codes up or down one row at a time, move a code to the top of the list to make it the primary procedure code, or move a code to the bottom of the list. 5. Click Save/Exit. Completing the Exam After coding the exam, click the Finalize icon in the top left of the ExamWRITER chart window. Selecting this icon does not keep you from making changes in the chart-it opens the Exam Finalization window, where you will have a choice to either Close record (changes permitted later) or Finalize record (NO Changes permitted, ADDENDUM only). Tip: Think of the Finalize radio button as the patient is ready to check out. If the Exam Review indicates that the Coding is Incomplete, click Continue; otherwise, select the Activities that you want to perform. Page 38

39 Finalizing Multiple Records 1. Click the Chart Search tab on the ExamWRITER Control Center window. 2. Search for a group of exams to finalize: a. Choose a date range for your search from the date From and to boxes. b. Select an exam status from the Status drop-down menu. c. Select a provider from the Provider drop-down menu. d. Click Search 3. Click Finalize. The Confirm window opens. Page 39

40 4. Click Yes to finalize all of the closed exams that are displayed. Appendix A: Navigating in ExamWRITER Within an open record, use the following tools to record exam information: Tool Bar Icons Click these icons located at the top of the exam record. Tabs Click to enter different categories of the exam. Category Bars Click on the Reason For Visit category bar to document information. Right click This tool is used most often used to delete information, but there are exceptions. For example, in the Reason for Visit and History of Present Illness categories, there are times when you click to select an item and then right click to save it in the record (black arrow). Appendix B: Function Keys Pressing certain function keys allows you to easily access information: F1 Opens the Help window and displays information about the task you are presently performing. F3 Opens the Orders menu. F4 Opens a Patient Letter containing a brief explanation of the diagnosis and tests recorded in the exam. Page 40

41 F6 Opens the Medication Orders menu. F12 Opens list boxes for additions and editing. Appendix D: Online Resources Recordings are available 24 hours a day; 7 days a week on our web site. View the recordings: When beginning to use ExamWRITER After you have used ExamWRITER for several weeks When you receive an ExamWRITER upgrade Recorded Tutorials: available 24/7 Documentation Webinar Series: available 24/7 In addition to the recorded tutorials, OfficeMate has a valuable quick reference tool, the Knowledge Base. The Knowledge Base allows you to submit questions and search by keyword for answers to specific questions that other ExamWRITER users have asked. You can access the Knowledge Base by clicking on Help while in the ExamWRITER program, or by following this link: Appendix E: Live Training Options Registering for a Live, Instructor-led Question & Answer session is easy! 1. Go to officemate.webex.com. 2. Click the Daily tab. 3. Use the calendar within this tab to select your desired Q&A session date. 4. Click Register next to the session you want to enroll. 5. Type your First name, Last name, address (the address used by your entire office staff), Company, and Office Phone Number. 6. Click Register. That s it! You ll receive confirmation with the Session password, Registration ID, and link you need to join the session. Page 41

42 ExamWRITER Q&A Time Days 12:00 12:45 PM Pacific Every Tuesday 12:00 12:45 PM Mountain Every Wednesday 12:00 12:45 PM Central Every Thursday 12:00 12:45 PM Eastern Every Friday ExamWRITER Tips & Tricks Time Facilitator Date 12:00 12:30 PM Eastern 12:00 12:30 PM Central 12:00 12:30 PM Mountain 12:00 12:30 PM Pacific Dr. Lorie Lippiatt Dr. Ryan Wineinger Dr. Kim Castleberry Rebecca Johnson First Friday of each month Second Tuesday of each month Third Monday of each month Fourth Wednesday of each month Private Online Courses Private online courses can be scheduled at a time that is mutually convenient for your office and our trainers to cover particular areas of concern specific to your office. These courses are available only after you ve completed your regularly scheduled online instructor-led courses. Each private course is $ per hour. Call our training department at , select option 3, and then select option 1 to schedule private courses. Page 42

43 Onsite Training Consultation An OfficeMate Implementation Trainer will come to your office to work with you and your staff to improve your understanding of your software's functionality and/or assist you when you go live with the software. All of our Implementation Trainers have several years of ophthalmic background and have a first-hand understand of the challenges that you face in your office. Call our training department at , select option 3, and then select option 1 to receive a price quote for an onsite consultation. Page 43