Selecting the Codes

1. Click the Coding icon in the top-left corner of the ExamWRITER chart window.

   The Diagnosis/Procedure Coding window opens.

   If a No Data error occurs when you open the Diagnosis/Procedure Coding window, click OK and see Setting Up Product and Service Information in ExamWRITER to add services to your exam.
2. Click the Diagnosis tab.

   The diagnosis codes for the impressions that you recorded in the exam appear in the Diagnosis table. They are based on the setup options of the patient’s primary insurance carrier in the Insurance Billing Initial Setup window in Administration.

   By default, the ICD-10 codes shown in the table are H52.x and H53.x refractive error codes, listed in numerical order. To view all the diagnosis codes, select All in the View Diagnosis box.
3. Add diagnosis codes to the Selected Diagnosis table as follows:
   • To add codes manually, double-click each code you want to add.

   • To populate the table automatically, click Auto Code.

     • To view information from MedlinePlus Connect about selected diagnosis codes, click the Info button in a code’s row.
     • To remove H52.x and H53.x ICD-10 codes from the Selected Diagnosis table, click Clear H52.x/H53.x.
     • To add an ICD-10 code that was not auto-coded during an exam due to its complexity and is not available to select, press F12 and then search for and select the missing ICD-10 code in the Add ICD-10 Code window.
     • If you copied forward a previous exam or changed, added, or reselected impression, special testing, or surgery information, click Clear All and then click Auto Code to populate the Selected Diagnosis table with codes from the previous and new exam records.
     • If there are no diagnosis and procedure codes to record for this exam, click No Diagnosis/No Procedure.
     • To open the E & M Quick Code Check window and reference quick code information, click Quick Code. For more information, see Using Quick Code.
4. If multiple SNOMED codes are associated with a selected diagnosis code, double-click the code and select the appropriate SNOMED code.
5. (Optional) To delete the diagnosis codes from the Selected Diagnosis table and manually record the codes and modifiers:
   1. Click Clear All.
   2. From the Modifier drop-down lists, select modifiers for the diagnosis codes that you want to use.
   3. Double-click the appropriate diagnosis codes to move the selected codes and modifiers to the Selected Diagnosis table.
6. To rearrange or delete the codes in the Selected Diagnosis table, click the arrows to the left of the 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 diagnosis code, or move a code to the bottom of the list.

   Any diagnosis code moved to the top row of the Selected Diagnosis table automatically appears in the DIAG 1 column on the Link Codes tab. After changing (even automatically) the diagnosis code selected from the DIAG 1 drop-down list, make sure the selections in the DIAG 2, DIAG 3, and DIAG 4 lists are in the correct order of precedence.

7. For VSP exams, select the appropriate VSP EHM check boxes to participate in the Eye Health Management program.

   The VSP EHM check boxes may already be selected based on the findings recorded in the exam or from the patient’s history.

   The EHM information, associated ICD-10 codes, and dilation information are sent when the claim and order are transmitted to VSP.

8. Click Save/Exit.

   Although you can select an unlimited number of diagnosis codes in ExamWRITER, only the codes listed in the first twelve rows of the Selected Diagnosis table appear on the ExamWRITER chart window and transfer to OfficeMate and Box 21 in the CMS 1500 form.

For more information, watch this video.

1. Click the Coding icon in the top-left corner of the ExamWRITER chart window.

   The Diagnosis/Procedure Coding window opens.

   • Before you code an exam, you must select CPT codes for your services to display the services in the Diagnosis/Procedure Coding window. If a No Data error occurs when you open the Diagnosis/Procedure Coding window, click OK and see Setting Up Product and Service Information in ExamWRITER to add services to your exam.
   • Click Quick Code to open the E & M Quick Code Check window and reference quick code information. For more information, see Using Quick Code.
2. Click the Procedures tab.

   The procedure codes are automatically displayed in the Selected Procedures table based on the preferences of the patient’s primary insurance carrier and your exam selections.

   • To comply with the Health Information Technology for Economic and Clinical Health Act (HITECH Act) and support the CMS Physician Quality Reporting System (PQRS), PQRS procedure codes automatically appear on the Procedures tab when associated diagnoses are recorded in the exam.
   • If you copy forward a previous exam containing PQRS procedure codes to a new exam, only 1036F and G0030 are copied forward.
   • The only procedure codes that are copied forward to new exams are 92012–92015, 92310, 99211–99215, and S0620.
   • For procedure codes to automatically appear in ExamWRITER after you upgrade from a previous version, you must create new services in the Products window and select the appropriate new level II procedure code from the CPT drop-down list for the services. You must do this before you can record the new level II procedure codes on fee slips in OfficeMate. For more information, see Setting Up Product and Service Information in ExamWRITER.
   • By default, the S-Codes and the 92xxx (nonmedical or “wellness visit”) procedure codes are shown in numerical order.

     To see other procedure codes, select the following options in the View Procedures box:

     • All shows all codes.
     • 992xx shows the evaluation/management (E/M) or “sick eye visit” codes.
     • PQRI shows the PQRS codes.
   • To view only the services that you use frequently, select Show Quick List. For information on adding services to your Quick List, see Setting Up Product and Service Information in ExamWRITER.
3. To add modifiers to procedure codes, right-click the Mod1 and Mod2 columns in the row of an appropriate procedure, and then click a modifier in the Select a Modifier window.

   Before you can select a second modifier in the Mod2 column, you must select a modifier in the Mod1 column.
   
   Modifiers do not transfer to OfficeMate fee slips or CMS 1500 forms.

4. Add procedure codes to the Selected Procedures table as follows:

   • To add codes manually, double-click each code you want to add.

   • To populate the table automatically, click Auto Code.

   • Before you can manually or automatically add procedure codes to an exam, you must select CPT codes for your services. For more information, see Setting Up Product and Service Information in ExamWRITER.
   • For the auto-code feature to work properly with unilateral procedure codes (92226, 92135, 76519, 92225, and 92235), make sure that separate unilateral procedure codes for each eye are set up in the Customization window (Procedure Codes tab) in OfficeMate or ExamWRITER (for example, 92226 RT and 92226 LT) before coding exams.
   • For the auto-code feature to work properly with surgical procedure codes (67850, 68200, 68810, 67515, and 65860), also make sure that the procedure codes are set up in the Customization window. Then open the services in the Products window, and select the appropriate right or left eye modifier for the procedure code. For more information, see Setting Up Product and Service Information in ExamWRITER.
   • To remove PQRS procedure codes that were automatically populated in the Selected Procedures table, click Clear PQRI. If you copied forward a previous exam, only 1036F and G0030 PQRS codes are copied forward, so if you modified any PQRS exam selections in the current exam, you must click Clear PQRI and then click Auto Code to populate the Selected Procedures table with codes from the previous and new exam records.
5. (Optional) To delete the procedure codes from the Selected Procedures table and manually record the codes and modifiers:
   1. Click Clear All.
   2. From the Mod drop-down lists, select modifiers for the procedure codes that you want to use.
   3. To move the codes and modifiers to the Selected Procedures table, double-click the appropriate codes.
6. To rearrange or delete the codes in the Selected Procedures table, click the arrows to the left of the 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.
7. Click Save/Exit.

   Only the first 20 procedure codes selected in a new exam and listed in the Patient Open Charges window transfer to a patient’s fee slip. If you do not want to post these charges, select them and click Close out.

   If you selected 992xx procedure codes and have not yet assigned a risk factor to your medical decisions, the Risk Factors window opens. To record a risk factor, click None, Minimal, Low, Moderate, or High.

   If you select a 992xx procedure code, the E & M Quick Code Check window automatically opens so that you can reference quick code information. For more information, see Using Quick Code.

For more information, watch this video.

You can link up to four diagnosis codes to each procedure code for insurance billing. Linked diagnosis codes+ procedure codes+ insurance carriers are transferred to OfficeMate fee slips and to CMS 1500 forms/ANSI insurance claims.

By linking diagnosis and procedure codes, you can bill different codes to different insurance carriers, depending on the insurance carrier’s rules and plans.

1. Click the Coding icon in the top-left corner of the ExamWRITER chart window.

   The Diagnosis/Procedure Coding window opens.

2. On the Diagnosis and Procedures tabs, make sure diagnosis and procedure codes are selected. See To select diagnosis codes and To select procedure codes.

   The first diagnosis code that you select on the Diagnosis tab is the default diagnosis code that is linked to procedure codes.

3. Click the Link Codes tab.
4. Select a procedure.
5. From the DIAG drop-down lists, select the diagnosis codes that you want to link to the procedure.
6. Associate an insurance carrier with a procedure:
   1. Select one or more procedures.
   2. In the Patient Insurance table, double-click an insurance carrier.
   3. Do one of the following:
      • To associate the insurance carrier with all selected procedures, click Apply Insurance.
      • To remove the insurance carrier from all selected procedures, click Remove Insurance.
7. Click Save/Exit.