Encounter Forms. 70 Royal Little Drive. Providence, RI Copyright Optum. All rights reserved. Updated: 3/8/13

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1 Encounter Forms 70 Royal Little Drive Providence, RI Copyright Optum. All rights reserved. Updated: 3/8/13

2 Table of Contents 1 Encounter Form Setup Overview Building an Encounter Form Printing Individual Encounter Forms Encounter Forms Overview Scheduling Mini-Menu: Instant Encounter Form Encounter Form Options Printing Instant Encounter Forms...9 ii

3 1 Encounter Form Setup 1.1 Overview The Optum PM and Physician EMR Enrollment Department builds encounter forms for clients when they decide to use Optum PM and Physician EMR as their practice management system, however, you can use the Encounter Form Setup application to build a custom encounter form for your practice. You can print the encounter forms based on appointments scheduled in the Book application either individually or in a batch. When a provider uses paper encounter forms to capture CPT and ICD-9 codes for a patient's visit, you must manually enter the procedure and diagnosis codes into Optum PM and Physician EMR via the Visit window or the Charge application of the Transactions Module. 1.2 Building an Encounter Form To build an encounter form: 1. Click the Administration module and then click the Setup tab. 2. Click the Encounter Forms link. Optum PM and Physician EMR launches the Encounter Forms application. 3. Click New. Optum PM displays the encounter form setup fields. 4. Enter a descriptive name for your encounter form in the Name field. 5. From the Style list, select Default. 6. The default settings for the following fields typically do not need to be changed when initially building the form: Font Size: 7 is the default font size for the header, body and footer of the encounter form. It is best to wait until your encounter form is built before changing the font size. Columns: 3 is the default number of procedure and diagnosis columns. This is how most encounter forms are typically set up. The number of either procedure or diagnosis columns can be changed. Cell wrap refers to the text that will display next to each code and determines whether or not the text will continue onto the next line. The default is Yes, but if you have a high volume of codes to add to your form, you may want to suppress the wrap feature. It is best to wait until your encounter is built to determine if you need to limit the text for either the CPT or diagnosis descriptions. Active: Select Y in the Active field so that the encounter form can be used. 7. Click Save. Optum PM displays the following buttons: Procedures, Diagnosis, Procedure Categories, and Diagnosis Categories. Note: You must build Procedure and Diagnosis Categories before actual procedure and diagnosis codes can be added to the encounter form. Categories determine the headings that will display in 1

4 Encounter Forms both the Procedure and Diagnosis section of the encounter form and how you will group your codes. For example, Procedure Categories could be, Consult, Office Visit New, Office Visit Established or Injections and Diagnosis Categories could be, Ankle or Back. 8. Click Procedure Categories. Optum PM displays a list of procedure categories. Depending on the number of columns you set for procedures, you will see a corresponding number of columns labeled as Table 1, Table 2, Table 3, etc. Typically, you will have three columns. a. Left-click on the procedure category you want to add, drag it over to the desired column and release the mouse button. Commonly, you will have multiple procedure categories in one column. The order in which they appear here determines the order in which they will appear in on the encounter form. After a category is placed in a column, it can be re-ordered by leftclicking on it and dragging it to a new location. Select all required procedure categories for your encounter form and verify they are in the correct order in each column. Note: At least one procedure category needs to be selected for each column. When the procedure codes to be included on the encounter form do not need to be sectioned or categorized, simply select 'Procedures' as the only category for each column. If you need a procedure category that is not listed, please send a ToDo to our Support Department. b. Click Save. 9. Click Diagnosis Categories. Optum PM displays a list of all Optum PM and Physician EMR diagnosis categories. Depending on the number of columns you set for your diagnosis codes, you will see a corresponding amount of columns labeled as Table 1, Table 2, Table 3, etc. Typically, you will have three columns. 2

5 Encounter Form Setup a. Left-click on a diagnosis category you need to add, drag it over to the desired column, and then release the mouse. Commonly, you will have multiple diagnosis categories in one column. The order in which they appear here determines the order in which they will appear in on the encounter form. After a category is placed in a column, it can be re-ordered by leftclicking on it, dragging it to its appropriate location, and releasing the mouse. Select all required diagnosis categories for you encounter form and verify they are in the correct order. Note: At least one diagnosis category needs to be selected for each column. When the diagnoses codes to be included on the encounter form do not need to be sectioned or categorized, simply select 'Diagnosis' as the only category for each column. If you need a diagnosis category that is not listed, please send a ToDo to our Support Department. b. Click Save. 10. Click the Procedures button and then click Add. Optum PM displays a procedure line. The sequence determines the order in which the codes will be listed under the category you select from the Category list. a. Enter a procedure code in the CPT Code field and press the [Tab] key. If you only entered a partial code, Optum PM displays the Procedure Search window. Click on the code you want to add. When the code is selected or immediately after the [Tab] key is pressed the procedure code name will display in the Procedure Name field. The CPT code description can be edited if 3

6 Encounter Forms desired. This will be the description that will display on the encounter form but the description in the data base is the description that will display on the visit window or the Charges application. b. Select the category under which you need this procedure code to display from the Category list. c. Click More to add additional procedure codes. d. Click Save. Optum PM displays the new procedure codes in the top frame of the screen. 11. Click Diagnosis and then click Add. Optum PM and Physician EMR displays a diagnosis line. The sequence in which the codes are entered determines the order in which the codes will be listed under the category you select from the Category list. a. Enter a diagnosis code in the Code field and press the [Tab] key. If you only entered a partial code, Optum PM displays the Diagnosis Search window. If the Diagnosis Search window displays, click on the code you want to add. When the code is selected or immediately after the [Tab] key is pressed the diagnosis description will display in the Diagnosis field. The diagnosis description can be edited if desired. This will be the description that will display on the encounter form but the description in the data base is the description that will display on the visit window or the Charges application. b. From the Category list, select the category under which you want this diagnosis code to display. c. Click More to add additional diagnosis codes. d. Click Save. Optum PM displays the new diagnoses codes in the top frame of the screen. 12. When all procedure codes and diagnosis codes have been entered click Preview and Optum PM displays a sample of the encounter form in the lower frame of the screen. Print the sample by right-clicking on top of the image and selecting Print from the pop-up menu. 1.3 Printing Individual Encounter Forms You may have to print individual encounter forms when the patient's appointment was not scheduled when the batch of encounter forms for the day were printed. This may occur if the patient's appointment was squeezed in, if they are a walk-in or in an emergency situation. Individual (instant) encounter forms can be generated and printed in several places in Optum PM and Physician EMR: The Book application of the Scheduling module. See: "Instant Encounter Forms" 4

7 Encounter Form Setup The Appts button in the Name Bar. See: "Viewing Appointments" The Appointment List link under the My Lists section of the Dashboard. See: "Appointment List Encounter Form" The Encounter Forms link under the Scheduling heading in the Reports module. See: "Printing Individual Encounter Forms" Note For multi-location, single group practices, encounter forms can be printed to display each location's address instead of the group address. If your encounter forms require location addresses, please send a ToDo to the Support Department. 5

8 2 Encounter Forms Overview Some providers use paper encounter forms to check off CPT and ICD-9 codes relative to a patient's appointment. Paper encounter forms are printed from Optum PM and Physician EMR based on appointments scheduled in the Book application, and can be printed either individually or in a batch. By clicking on the Encounter Forms link under the Scheduling heading in the Reports application you will be able to print an encounter form for each patient with a scheduled appointment on a particular date of service. Encounter forms printed by batch can be filtered to only include a specific location, provider, appointment type, time, group, appointments created during a specific date range, and patients created during a specific date range. Procedure and diagnosis codes selected on the paper encounter form will need to be electronically entered into Optum PM and Physician EMR through the Visit window or Charge application in the Transactions Module. The heading on an encounter form contains the patient's pertinent demographic data - name, chart number, Optum PM and Physician EMR ID number, address, phone number, PCP, secondary insurance (if applicable), the payer's name, the subscriber number and the co-payment amount. The appointment information that is shown on the encounter form includes the appointment type, the location, and the provider with whom the appointment is scheduled. If the appointment is linked to a referral and/or authorization, that data will also print on the encounter form heading. There are particular encounter form options that can be set up at the group level for each group within your company including, balance information, complaints, appointments, and diagnoses. You can choose whether or not to have patient outstanding balances print in the lower, right-hand corner of the encounter form. When you elect to print balance information, you can then determine whether to only print the patient's balance or to print the total outstanding balances for all family members linked to the patient. Patient complaints can be entered in the "Complaint" field of the Book Appointment window when an appointment is being scheduled. For each group you can determine whether or not a complaint linked to an appointment prints in the top, left-hand corner of the encounter form. If you have multiple groups within your practice, you can also determine whether or not previous diagnoses and upcoming appointments for the patient prints on the encounter form for only the current group from which the form is being printed or for all groups within your Parent Company. FYI: For multi-location, single group practices, encounter forms can be printed to display each location's address instead of the group address. If your encounter forms require location addresses, please send a ToDo to the Support Department. How to Print Batch Paper Encounter Forms 1. Click on the Reports module icon. 2. Click on the Encounter Forms link under the Scheduling Reports heading. 6

9 Encounter Forms 3. When the Encounter Forms link is clicked, the Order/Filter By screen displays. The current date will display in the "Appt Date From/To" fields, click on the Go button if this is the date you wish to print encounter forms for, or use any of the fields as needed to filter the encounter forms to print, and then click on the Go button. FYI: The "Order by" will default to 'Appointment Time' if one is not selected. The "Select Enc Letter" field will print the different encounter forms based on the type of the appointment if a specific form is not selected. 4. When the Go button is clicked, the encounter forms matching any filters set for the selected date will display in the bottom frame of your screen. To print the encounter forms, right click on top of the first encounter form and select 'Print' from the grey pop-up menu. 7

10 Encounter Forms Related Topics: Instant Paper Encounter Forms Overview (Scheduling Module); Printing Instant Paper Encounter Forms (Scheduling Module); How to Print an Instant Encounter Form (Name Bar) 8

11 3 Scheduling Mini-Menu: Instant Encounter Form Encounter forms are used to record procedure and diagnosis codes for a patient's appointment. Typically, encounter forms are printed in a batch based on the appointments scheduled in the Book application. Encounter forms are printed individually when the patient's appointment was scheduled after the day's batch of encounter forms were printed. Individual (instant) encounter forms can be generated and printed in several places in Optum PM and Physician EMR: The Scheduling mini-menu in the Book application of the Scheduling module The Appts button on the Name Bar The Appointment List link on the Dashboard 3.1 Encounter Form Options You have the option to include or exclude the following information on your encounter forms: The patient's outstanding balance The total outstanding balances for all family members linked to the patient Patient complaints linked to an appointment For multi-location, single group practices, display each location's address instead of the group address Note: Send a ToDo to your support entity to enable or disable these encounter form options. 3.2 Printing Instant Encounter Forms To print an instant encounter form: 1. Click the Scheduling module. Optum PM displays the Book application. 2. Left-click on the name of the patient in the schedule for whom you want to print an encounter form. Optum PM displays the mini-menu. 3. Click Enc Form on the mini-menu. Optum PM displays the patient's encounter form. 4. Right-click on the encounter form and select Print from the shortcut menu. Windows displays the Print dialog box. 5. Click Print. 9

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