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The Allscripts Enterprise EHR Charge module captures and reviews professional services for patient encounters. This can be accomplished in several ways:
- Order Entry Module - the Order Entry module in Allscripts Enterprise EHR can be used to generate Procedure Charges. Orderable items that have CPT linked to them and are set to generate charges upon order, collection or completion can populate the Procedure Charges page of the Charge module.
- Note E/M Coder - the Note E/M Coder can be used to generate Visit Charges for the Charge module. The E/M coder can calculate a suggested level of service for the visit based algorithms that evaluate discrete data elements contained within certain note sections. The E/M Expert provides Evaluation and Management coding assistance in accordance with HCFA E/M Guidelines (1995). Using the E/M Expert, you can describe the characteristics of a visit and derive an appropriate visit charge based on that criterion. The E/M code can also be manually populated in situations where varying amounts of text or dictation are using to document the visit.
- Problem module/structured note - Assessing items on a patient's problem list can be used to generate Diagnosis charges for the Charge module. By either assessing problems directly from the Problems workspace or from the appropriate section of a structured note the system can drop the ICD9 code associated with the problem to the Diagnosis page in the charge module.
- Manually selecting from a defined group or specialty listing within the Charge module that has been created in TWAdmin. Groups provide a hierarchical structure for grouping diagnoses and visit and procedure codes, as well as orderable items. For selector lists longer than 75 items, creating groups and subgroups can minimize the time required to find an item. Groups are typically based on specialty (internal medicine, pediatrics, etc.) or site (such as clinic, hospital, or nursing home).
- Searching the "Master" for diagnosis, visit or procedure line items to add to the Encounter Form.
- Automatically generated based on previously entered information.
The option of Medicare medical necessity checking is available.