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B12 Injection Nurse Visit

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In this Quick Reference Guide, users will learn how to properly document B12 Injections during Nurse Visits. This Reference Guide assumes that users have a basic understanding of how to access patient records and navigate to the Intake MG template.

Nurse Visit Type

After launching the Intake MG template:

  1. Select Nurse Visit from the Visit Types pop-up menu.
  2. Click OK

Historian

The Historian is the individual/(s) who provide information to the Nurse during Intake. To record this information:

  1. Click the Historian field.
  2. Select Self from the pop-up menu.

Use the Addt'l Historian/(s) field to record additional historians and their relationship to the patient. Information can also be free texted into the Historian fields.

Reason for Visit

In the Reason for Visit Panel:

  1. Free text Nurse Visit B12 Injection in the Other field.
  2. Click Add.

HPI

In the Generic Free form template:

  1. Free text pertinent information in the HPI section of the template.
  2. Click Save & Close

My Phrases can be created and used to help expedite repetitive HPI documentation. (See How to Create My Phrases training material for details.)

Vital Signs

From the Vital Signs panel; click Add

In the Vital Signs template:

  1. Record patient Vital Sign information.
  2. Click Save
  3. Click Close

Adding Diagnosis Code

A diagnosis is required to order any Office Services. To add Diagnosis Code/(s) for today's visit; select Assessment from the Intake navigation bar.

Click the Diagnosis Code Lookup button from the Assessment template.

Diagnoses can be selected from the patients Assessment History and Problems grids if previously used. (See image below)

Searching for Diagnosis

In the Diagnosis Code Lookup window:

  1. Free text description of Diagnosis in Search field.
  2. Select Diagnosis from result lists.
  3. Click Select.

Ensure that the All Diagnoses option is selected before searching for diagnosis. (See Image Below)

Diagnosis Status

From the Diagnosis Status pop-up:

  1. Select the Acute option.
  2. Click OK.

Click Save & Close to exit Assessment template.

Accessing Office Services Template

The B12 Injection is ordered from the Office Services template. To order the B12 Injection:

  1. Click the Office Procedures tab *
  2. Select the Diagnosis from the Today's Assessments list.
  3. Click the Miscellaneous drop down arrow to access the pick list.
  4. Select Vitamin B12 injection Up to 1,000mcg from the list.
  5. Click OK
  6. Select the Injection radio button.
  7. Click Place Order.

* The Office Services template can also be accessed from the Intake Navigation bar.

Submitting Services for Billing

Assuming that the injection has already been given to the patient; double-click the order in the Orders grid.

From the Office Procedures Orders template:

  1. Click the Completed check box. *
  2. Document the Result details.
  3. Click Update.
  4. Enter Injection details.

* Clicking the Completed check box automatically selects the Performed check box.

Adding Administration Code

The administration of the B12 Injection must also be billed. To add the Administration Code:

  1. Click inside the Admin/other 1: field.
  2. Select Therapeutic Prophylactic/Dx injection Subq/Im 96372
  3. Click OK

After selecting the Administration code:

  1. Click Submit to Superbill.
  2. Click Save
  3. Click Close

A/P Details

Advance to the A/P Details tab:

  1. Select Diagnosis from Today's Assessments list.
  2. Document patient instructions in the Patient Details section.

Follow Up

To document Follow Up information:

  1. Click the Follow Up button.
  2. Select Diagnosis.
  3. Click follow up check box.
  4. Click Timeframe field to select Follow-up visit timeframe.
  5. Click Place Order
  6. Click OK
  7. Click Save & Close (twice)

Generate Patient Plan

To Generate the Patient Plan:

  1. Advance to the SOAP template.
  2. Click Patient Plan icon at the bottom of the template.

The SOAP panels in this illustration have been collapsed.

Generate Master Document

To Generate the Master Document for the Nurse Visit:

  1. Click Generate Note icon at the bottom of the SOAP template.
  2. Select Master Document from pop-up list.
  3. Click OK

Important Note

ANY INJECTIONS (I.E. B12, TORADOL, KENALOG, ETC.), OTHER THAN VACCINES. NEED TO BE CODED ALSO WITH THE INJECTION CODE 96372.

DO NOT CODE THE 92211 FOR NURSE VISIT AS THE CODE 96372 COVERS THE NURSE VISIT CHARGE.

CODE THE 99211 FOR ANY NURSE VISITS FOR EAR LAVAGE, BLOOD PRESSURE CHECKS, EKG, OR ANY OTHER PROCEDURES.

Verifying Code Submission

It is important to verify that both the Injection and the Administration Codes have been properly submitted for billing. To Verify Code Submission:

  1. Click Procedures Module icon.
  2. Verify that both the Injection and Administration Codes have been submitted.
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