Entering Details for Common Plans

Within Encompass, there are hundreds of plans. This section discusses entering details for many commonly-used plans. The topic describes how

  1. In the Plans section, click Bandage/Therapeutic Contact Lens.
  2. Click the exact location on the eye diagram.

    Sliders appear to allow you to scale and rotate the location of the condition.

  3. On the Details screen, select the Detail Level.
  4. Select the Indication, Anesthesia, Complications and Bandage Contact Lens.
  5. As needed, click additional options at the top of the screen:
    • Click Medications if any post-operative medications will be administered. Select the Post Op Meds that will be administered to the patient. Enter the instructions for using the medication in the text box.
    • Click Consent to review the patient's consent.
    • Click Post-care to review or edit the patient's post-care instructions.
  6. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Contact Lens Assessment.
  2. On the Details screen, select the Detail Level.
  3. Select a level for the Contact Lens Fitting Fee.

    If you select a level, the level will be sent to the practice management side when you finalize charges. Keep in mind that the Price field is for documentation in Encompass only and will not be sent to the practice management side.

    At the top of the screen are additional options related to the contact lens assessment. All of these options are set to normal. You only need to record any abnormal findings.

  4. As needed, click additional options at the top of the screen:
    • Click Fit to see a list of possible fitting problems.

      Select the fit for the right and left eye.

    • Click Comfort to see a list of comfort levels for the contact lenses.

      Select the comfort level for the right and left eye.

    • Click Vision to see various problems with the clarity of vision provided by the contact lenses.

      Select the clarity of vision for the right and left eye.

    • Click Lens to see various problems that may affect the contact lenses.

      Select any problems with the lenses for the right and left eye.

    • Click Ocular Health to see a list of ocular health problems that may affect the patient.

      Select any ocular health problems for the right and left eye.

    • Click Other.

      Enter any other information regarding the contact lenses for the right and left eye.

    • Click Plan.

      Select the Plan.

      Select the recommended soft lens and RGB lens.

      Select the Care Recommendations.

    • Click Parameters.

      Select the Change Parameters for the right and left eye.

    • Click Monovision.

      Select whether the contact lenses are for monovision for the right and left eye.

    • Click Lens Counseling.

      In the Education Checklist, select the check box for the items on which the patient was counseled.

      In the text boxes, enter the details of the counseling the patient received.

  5. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Counseling.
  2. On the Details screen, select the Detail Level.
  3. Select whether you want full counseling or abridged counseling to appear in the visit note.
  4. Select the check box for each Counseling Block you reviewed with the patient. Edit the counseling block with your counseling instructions, if necessary.
  5. Click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Epilation.
  2. On the Details screen, select the Detail Level.
  3. Select the type of Procedure(s) performed.
  4. Select the Location where the procedure was performed.
  5. Select the Indication for Epilation.
  6. Select the Anesthesia.
  7. Select Complications, if any.
  8. As needed, click additional options at the top of the screen.

    These options are related to the type of procedure performed. The options contain a procedure note, patient consent, and post-care instructions. You only need to edit an option to record any abnormal information.

    The options are:

    • Forceps. If epilation forceps were used, click Forceps to review a description of the Forceps Note, the patient's Consent, and Post-care Instructions.
    • Cryotherapy. If cryotherapy was used, click Cyrotherapy to review a description of the Cryotherapy Note, the patient's Consent and Post-care Instructions.
    • Electrosurgery. If electrosurgery was used, click Electrosurgery to review a description of the Electrosurgery Note, the patient's Consent and Post-care Instructions.
    • Laser. If a laser was used, click Laser to review a description of the Laser Note, the patient's Consent and Post-care Instructions. You can also select the Laser Type, Spot Size, Power, Pulse duration and Total Shots.
    • Billing. Select the CPT Modifier to be used for billing.
  9. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Extended Opthalmoscopy.
  2. On the Details screen, select the Detail Level.
  3. Select the Location where the ophthalmoscopy was performed.
  4. Select the Status of the ophthalmoscopy.
  5. Enter the reason why the ophthalmoscopy was a Medical Necessity.
  6. To indicate how to bill for the procedure, click Billing at the top of the screen.

    If the ophthalmoscopy was performed bilaterally, select whether to bill as one line item or two line items.

  7. When you have finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click External Photos.
  2. On the Details screen, select the Detail Level.
  3. Select the Location where the external photos were taken.
  4. Enter whether there was any Other Indication.
  5. Select the Reliability of the Study.
  6. As needed, click additional options at the top of the screen:
    • Click Findings to see a list of the potential findings for the right and left eye. Select your findings for the right and left eye.
    • Click Diagnoses to select the Diagnosis for the right and left eye.
    • Click Assessment and Plan to document your assessment and any future plans.

      Some insurance plans will not reimburse for external photos assessed as baseline for future comparison.

    • Click Billing, and select whether you'll bill the patient for the professional component, the technical component, or both.
  7. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click F/U for Next Visit.
  2. On the Details screen, select the Follow-up Time Frame.

    If you select a follow-up time frame, it will be sent to your practice management system when you finalize charges.

  3. Select the Detail Level.
  4. Select the Plan for next visit as diagnostic, treatment, or both.
  5. Enter the Protocols to be followed on the next visit for the right and left eye.
  6. Click the check box for the Protocols to be followed on the next visit, entering the information for any exams, tests, and procedures to be performed as necessary.
  7. As needed, click additional options at the top of the screen.

    These options allow you to specify the exam, diagnostics, and procedures you want to perform for the patient’s next visit. The last option allows you to enter information for following up with another physician.

    The options are:

    • Exam. Select the exams you want to perform for the patient on the next visit.
    • Diagnostics. Select the diagnostics you want to perform for the patient on the next visit.
    • Procedures. Select the procedures you want to perform for the patient on the next visit.
    • Laser. Select the laser procedures you want to perform for the patient on the next visit.
    • Refractive. Select the refractive procedures you want to perform for the patient on the next visit.
    • Follow-up another Dr. Select the Follow-up time frame. Enter the Name of Physician to follow up with. Enter any Instructions for the patient.
  8. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click the Fundus Photos plan.
  2. On the Details screen, select the Detail Level.
  3. Select the Fundus Photos Location as the right, left or both eyes.
  4. Enter any Other Indication.
  5. Select the Reliability of study.
  6. As needed, click additional options at the top of the screen.

    These options allow you to specify findings for various structures of the eye. All of these options are set to normal. You only need to record any abnormal findings.

    Additional options allow you to select how the patient will be billed and to enter and an assessment and plan.

    The options are:

    • Vitreous. Select the condition of the Vitreous for the right and left eye.
    • ON. Select the condition of the Optic Nerve for the right and left eye.
    • Vessels. Select the condition of the Vessels for the right and left eye.
    • Macula. Select the condition of the Macula for the right and left eye.
    • Periphery. Select the condition of the Periphery for the right and left eye.
    • Diagnoses. Select the Diagnosis for the right and left eye.
    • Assessment and Plan. Select the Assessment for the fundus photos.

      Some insurance plans will not reimburse for external photos assessed as baseline for future comparison.

    • Future Plans shows a list of potential procedures and treatments. Click the check box for the procedures or treatments that could be performed for the patient in the future.
    • Billing. Select whether you'll bill the patient for the professional component, the technical component, or both.
  7. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click OTC Regimen.
  2. On the Details screen, select the Detail Level.
  3. Click the check box for the OTC regimens the patient will follow. Edit the description of the OTC regimen, if necessary.
  4. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Prescription.

    The Details screen shows a list of medications that can be used to treat the diagnosis.

  2. Select the medication you want to use, or click Find Other Medication to search for a new medication.

    You can click Grand Rounds to see a list of medications that other doctors have prescribed for the diagnosis.

    Medication lists and dosages are updated monthly. If you're looking for a medication that isn't listed, check its status on the FDA National Drug Code Directory.

  3. If Drug Interaction(s) is displayed, click it to display a list of drug interactions based on the patient's medications and allergies.
  4. When you've finished entering details for the plan, click Close to return to the Ocular Exam Room.
  1. In the Plans section, click Permanent Punctal Occlusion.
  2. On the Details screen, select the Detail Level.
  3. Select the Anesthesia used.
  4. Select Complications, if any.
  5. As needed, click additional options at the top of the screen. The options are:
    • RUL, RLL, LUL, LLL
      1. Click the appropriate location.
      2. Select the Punctal Occlusion Company.
      3. Select the PUNCTAL Occlusion Method.
      4. Enter the Punctal Serial/Lot Number.
      5. Select the Punctal Dilator.
    • Laser
      1. Select the Laser type.
      2. Select the Spot Size.
      3. Select the Fluence.
      4. Select the Pulse duration.
      5. Enter the number of Total Shots.
    • Consent. Review a description of the patient’s consent.
    • Post-care. Review a description of the post-operative care instructions given to the patient.
    • Billing.Select the CPT Modifier, if any.
  6. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Reassurance.
  2. On the Details screen, select the Detail Level.
  3. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Refraction.
  2. On the Details screen, select the Detail Level.
  3. Select the Location where the refraction was performed.
  4. Select the Refraction Type.
  5. Enter the reason why the refraction was a Medical Necessity.
  6. To override your visit billing with an S-code, click S-Codes at the top of the screen.

    Select whether you want to Override EM Visit Billing with an S-Code.

  7. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Suture Removal.
  2. On the eye diagram, select the location of the sutures.
  3. On the Details screen, select the Detail Level.
  4. Click the check box for the instructions the patient will follow. Edit the descriptions of the instructions, if necessary.
  5. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.
  1. In the Plans section, click Treatment Regimen.
  2. Select whether the Treatment Regimen is OTC, prescription drug management, or both.
  3. Use the drop-down lists to indicate what actions you're instructing the patient to take, or click the Free Form tab to enter the information manually.
  4. Select the Detail Level.
  5. Depending on whether you want to Continue, Discontinue, or Modify the regimen, enter the necessary details in the corresponding text box.
  6. Enter the details for the OTC Regimen, any Samples Given, or Other Instructions.
  7. When you've finished entering details for the plan, click Done to return to the Ocular Exam Room.