Procedures, Operative

For billing and reporting purposes, Procedures performed must be confirmed in either the CDM module or on the Charge Entry Screen in Financial Management. This topic covers updating Procedures information in the CDM module under the Operative Sheet Bar Heading. If there was a PAT or Follow-up appointment scheduled for the case, any Procedures performed during those appointments may be updated under the PAT/Follow-up Sheet Bar Heading.

Procedures information updated in the CDM module flows into Financial Management and vice versa.

To update/edit Procedures information, the case status must be set to one of the following: Performed, Partially Performed/Billable, Partially Performed/Not Billable, or In Progress. Procedures information will not be allowed to be entered if the case status is set to Pending or Cancelled. You can update the case status on the Case > General screen in CDM.

For information on integration with AmkaiCharts, SIS Charts, and/or SIS Advanced and workflow issues in the CDM module, see About the CDM module.

To update the CDM module with Operative Procedures performed

Launch the CDM module. You will be prompted to select a patient and case. Click herehere for more information, including instructions for selecting a patient and a case. The module opens to the Case > General screenCase > General screen ..
1. When you first open the CDM module, the Person -Patient selection dialog appears, prompting you to select a patient. Click here to learn how to select a patient record.
2. After you select a patient, the CDM Case Selection dialog CDM Case Selection dialog appears, prompting you to select a case. Highlight a case from the dialog and do one of the following:
Note: Only one user at a time can edit a case, but multiple users can view it at once. If you open a case someone else is already editing, a system prompt will indicate you are in View Only mode and let you know who has the case open for editing and for how long. Click the Refresh Locking Info button to see if the case has been released for editing.
Click Procedures under the Operative Sheet Bar HeadingOperative Sheet Bar Heading.
The patient information sectionpatient information section at the top of the screen auto-populates from the Scheduling module. Click the links below for more information about these fields:

PatientPatient

To select a different patient, click the check mark icon. The Person -Patient selection dialog appears. Click here to learn how to use this dialog to select a patient.
CaseCase

To select a different case, click the check mark icon. The CDM Case selection dialogCDM Case selection dialog appears. Select a case and click Edit to open the case for editing, or click View if you do not wish to edit the case.
Surgery DOSSurgery DOS

The Surgery Date of Service defaults in from the Scheduling module. Read-only field.
Appointment SummaryAppointment Summary

To view an appointment summary, click the calendar icon to the far right of patient information section (circled in red) to launch the Appointment Summary dialog. Click here to learn how to use this dialog.
RemarkRemark

To view or create a remark, click the icon (circled below) in the far right of the patient information section. Click here to learn how to use the dialog that appears. The number to the right of the icon indicates how many remarks exist on this account.

The scheduling information and times sectionscheduling information and times section may auto-populate from other areas. Click the links below for more information about these fields:

Scheduling InformationScheduling Information
Begin/End DateBegin/End Date

Either defaults in from the Scheduling module or from AmkaiCharts as the date of the appointment. You can change the Begin Date or End Date using the drop-down in the field, but if your facility is an ASC, you must also change the appointment date in the Scheduling module to avoid creating billing issues.
OR Begin TimeOR Begin Time

Defaults in if OR Begin Time was previously entered in Case > Times. You can change the OR Begin Time by entering a different time in this free text field, unless the time was exported from AmkaiCharts.
Time Out TimeTime Out Time

Defaults in if Time Out Time was previously entered in Case > Times. You can change the Time Out Time by entering a different time in this free text field, unless the time was exported from AmkaiCharts.
Incision Begin/End TimeIncision Begin/End Time

Defaults in if Incision Begin Time was previously entered in Case > Times. You can change the Incision Begin Time by entering a different time in this free text field, unless the time was exported from AmkaiCharts.
OR End TimeOR End Time

Defaults in if OR End Time was previously entered in Case > Times. You can change the OR End Time by entering a different time in this free text field, unless the time was exported from AmkaiCharts.
RoomRoom

Defaults in from the Scheduling module. To change the Room, select a different one from the drop-down list. Conflict Checker will alert you if the Room you select is not available.
Operative Billing RateOperative Billing Rate

This field is only used for time and material billing. If applicable, select an operative billing rate from the drop-down list or click Alt + D to launch the dictionary to create a new one.

Scheduled Procedures for the Operative phase of care default in from the Scheduling module in the Scheduled Procedures section as shown in this screen shot of the Procedures screenthis screen shot of the Procedures screen. If a Scheduled Procedure was actually performed, you can enable charges to be billed for it by highlighting the Procedure in this table and clicking Add. If there are multiple procedures listed, click Add All.
The selected procedures will now appear in the Procedures Performed tableProcedures Performed table. Click the following links to learn more about the functionality of this table:

Add additional performed procedures to the tableAdd additional performed procedures to the table
If a User Select preference Card was used to schedule the appointment, you can select procedures from that card to add to the table:
Select a batch for billing charges for the procedures shown in the tableSelect a batch for billing charges for the procedures shown in the table
1. Click No Batch. The Batch Selection dialog appears.
2. Click here to learn how to use this dialog to select or create a new batch.
Add additional details needed for a HCFA or UB claim formAdd additional details needed for a HCFA or UB claim form

Click here to learn more about the Case additional Information dialog that appears when you click Additional case info.

For all procedures listed in the Procedures Performed table, you must complete at least the MandatoryMandatory fields are those which much be completed with valid information before an appointment is saved. Your Business Entity can designate these fields in Conflict Settings in the Administration Module. Mandatory fields are highlighted in red in the application. fields in the Procedure DetailsProcedure Details section. Key information you enter in this section will then backfill into the appropriate fields in the Procedures Performed table. Highlight a procedure from the table to populate the Procedure Details section. Click the following links for more information about the fields in this section:

ProcedureProcedure

Click the check mark icon next to the Procedure field to access the Procedures dictionary. This is a Mandatory field.
Modified Procedure DescriptionModified Procedure Description

The description as entered in the Procedure Dictionary or entered on the scheduled case defaults into the Modified Procedure Description field. This is a free text field that you can edit as needed for this specific case.
The following fields are read-only:

CPTCPT®

Defaults in from the Procedure Dictionary.
Modified CPT®Modified CPT®

If you have set a carrier-specific CPT® code for this procedure in the procedure dictionary, that code will be displayed as read-only here.
ICD 1 - 3ICD 1 - 3

Default ICD-10 Procedure codes can be set in the procedure dictionary and will pull to these fields if set. Generally, only inpatient cases will require ICD-10 Procedure codes.
Insurance CarrierInsurance Carrier

The primary insurance carrier defaults in from the Billing Group assigned to the case at Scheduling.

Rend PrvRend Prv

The rendering physician defaults in to the Rend Prv field. You can select a different provider from the drop-down list.
Assistant 1 and Assistant 2Assistant 1 and Assistant 2

You can add any assistant surgeons using the drop-down list in the Assistant 1 and Assistant 2 fields.
Diagnosis CodesDiagnosis Codes

Use the + to add diagnosis codes. If you are working on AmkaiOffice Version 3.16x, you may enter up to 9 codes. If, however, you are working on Version 3.17b or greater, you may enter up to 18 codes.
Mod 1 -4Mod 1 -4

Select any modifiers from the drop-down lists at the Mod 1 -4 fields
ICD 1 -3ICD 1 -3

Select any ICD-10 Procedure Codes from the drop down menus in these fields. Generally used only for In Patient cases.
UnitsUnits

Number of times the procedure was performed. Defaults to 1.
Medicare Fee Grp #Medicare Fee Grp #

This field is no longer used as Medicare Contracts are no longer based on fee groups.
Source of RevenueSource of Revenue

Use the drop down menu to select the Source of Revenue for this procedure. SOR can be defaulted in the procedure dictionary. SOR is often used to apply discounts to second and additional tasks.

It is recommended that you avoid clicking Create Charge. Charges should be generated in the Financial Management module instead to ensure all billable supplies and G Codes are considered when the charges are posted.
Click one of the following buttons:
- SaveSave
  
  Click to save your changes to the patient's account and remain in this account in the CDM.
- Save & NextSave & Next
  
  Click to save your changes to the current record and search for the next patient whose record you wish to update in the CDM.