Work Flow- Clinical Documentation to Creating Claim

This lesson provides a recommended work flow for

  • Documenting the clinical visit and entering diagnosis and charge (CPT/HCPCS) codes
  • Creating a billing statement
  • Posting the billing statement to front office/billers
  • Processing charges
  • Creating a claim, as needed.

Note: This lesson will not be covering all of the steps/processes needed to fully document a clinical encounter in the SOAP note. The 2 sections in the SOAP Note that will be highlighted will be the Assessment section and the Plan section. Diagnosis codes will be entered into the Assessment section, and CPT/HCPCS codes will be entered into the Plan section. These 2 sections will be the two key areas that will transfer to the SW Practice Management system and primarily affect the billing/claims.

Create the SOAP note

Create the SOAP note

With the patient's chart open, in the Charts workspace of SOAPware:

  1. Click on the SOAP Notes tab,
  2. Click the Create Docutainer button to create a new encounter.

Enter the Diagnosis Codes for the visit (Assessment Section)

Enter the Diagnosis Codes for the visit (Assessment Section)
  1. Click into the Assessment section to activate.
  2. There are several methods in which to enter diagnosis codes into the Assessment section. Some of the most common methods are:

       - Selecting from the SMARText Quick Access list (This list will auto-populate with the most common diagnosis codes used by the user logged into SOAPware. To access this window, click on the Tools menu and click SMARText Quick Access. You can drag and drop that window to pin to an area of the chart, if desired. The list will be begin populating as you begin to use the system. The most commonly used codes will default towards the top.)

       - Typing in a descriptive word and searching the database by hitting F10 on your keyboard.

       - Creating a custom pick list of your most common diagnosis codes.

       - Defaulting the codes needed into a specific template that is associated with the type of visit.

3. Enter the needed diagnosis codes into the Assessment Section. (Sample shown in above image.)

 

 

Enter the CPT/HCPCS Codes for the visit (Plan section)

Enter the CPT/HCPCS Codes for the visit (Plan section)
  1. Click into the Plan section to activate.
  2. There are several methods in which to enter CPT/HCPCS codes into the Plan section. Some of the most common methods are:

       - Selecting from the SMARText Quick Access list (This list will auto-populate with the most common CPT/HCPCS codes used by the user logged into SOAPware. To access this window, click on the Tools menu and click SMARText Quick Access. You can drag and drop that window to pin to an area of the chart, if desired.The list will be begin populating as you begin to use the system. The most commonly used codes will default towards the top.)

       - Typing in a descriptive word and searching the database by pressing Shift + F11 on your keyboard.

       - Creating a custom pick list of your most common CPT/HCPCS codes.

       - Defaulting the codes needed into a specific template that is associated with the type of visit.

3. Enter the needed CPT/HCPCS codes into the Plan Section. (Sample shown in above image.)

 

 

 

Associate diagnosis codes with each CPT/HCPCS code

Associate diagnosis codes with each CPT/HCPCS code
  1. Click the Related Dxs sub-item for each procedure (CPT/HCPCS) code entered.
  2. Check the applicable diagnosis codes that relate to the procedure, as shown in the SMARText Quick Access window.
  3. Optional: If you would like to specifically order the diagnosis codes at this point, click the cell in the Order column to indicate the number order for each diagnosis. If the order is not specifically selected in this column, the order will default to the order in which the diagnosis codes are displayed in the Related Dxs subitem .
  4. Optional: Click on the Modifiers sub-item to associate any modifiers as needed for the procedure.

Create the Billing Statement

Create the Billing Statement

Click the View Billing Statement button.

Optional: Add Document task for Superbill Creation

Optional: Add Document task for Superbill Creation

When a billing statement is created, a window will pop up to associate a task with the new billing statement created. If you have a user in your clinic that will post these at a later time, this task can be assigned to them at this time, if desired. The purpose of this task box is to facilitate a method of tracking superbills that have been created and ensure that they get posted and not overlooked, resulting in lost revenue.

  1. Click Add to add a task.
  2. Click Cancel to continue without adding a task.

IMPORTANT: Once the Billing Statement has been posted, this task will automatically be removed from the assigned user's task list.

Review the Billing Statement

Review the Billing Statement
  1. Procedure codes are listed.
  2. Associated diagnosis descriptions are displayed next to the procedure code.
  3. Associated modifiers are displayed next to the procedure code.
  4. Optional: To prevent a procedure from being billed, you can click the X to the left to remove the item from the billing statement.
  5. Notes can be added to relay specific information pertaining to the visit to front office/billing staff.
  6. Click the Post Superbill button to post the billing statement.

Note: The Owner listed at the top of the billing statement will be the active provider in SOAPware when the billing statement was created. The Facility that is displayed will be the Active Facility on the Scheduler. Both Owner and Facility can be changed on the billing statement as needed by clicking each drop down.

Add Document Task for Superbill Posted

Add Document Task for Superbill Posted
  1. The User selected as the Superbill Task User in the Misc tab of Provider Manager will default to be assigned this task when the billing statement is posted. If a user has not been set in Provider Manager, the task will default to the active provider name, but can be changed from this dialog as needed.)
  2. Click Create to add the task for the specified user.

Note: If a user has been selected as Superbill Task User, this pop-up window will not be displayed, but a task will automatically be added  to that specified user's Task List.

Processing the Posted Billing Statement

From any location in SOAPware, the Task list can be displayed by going to the SOAPware menu and clicking Tasks. If front office staff are processing the posted billing statements/superbills and checking out patients, the task list can be docked within the Scheduler to allow for easy viewing of newly posted superbills/charges. If a back office billing staff member is processing these superbills, they can simply pull up their task list wherever it is convenient for them within SOAPware.

  1. With the appropriate user selected at the top of the task list, the newly posted superbill will be displayed in the list.
  2. To process the visit, double click the line item to open the patient's New Charges tab.

If you would like for your Task list to display the description, patient name and time modified to the left (as is shown in the above screen), drag and drop any of the columns around as needed.

 

Process/Post Visit Charges and Create Claim (As Needed)

Process/Post Visit Charges and Create Claim (As Needed)
  1. Double click on the charge to review for any changes.
  2. To change claim level information, click on More Info and edit as needed.
  3. If a co-pay was taken when the patient checked in, you can manually apply that co-pay to the newly posted charges by clicking Apply Co-Pay and distributing as needed.
  4. If you need to take a new payment, click Add Payment.
  5. If the patient has an active insurance policy, the Follow-Up Action will default to Submit to Insurance. If Submit to Insurance is selected as the Follow-Up Action, a claim will be created when the visit is posted. If you do not want to create a claim, select Do Not File. Patient Responsibility from the Follow Up Action drop down.
  6. If there is a Primary Insurance policy for the patient, it will be listed here. The policy can be changed/switched to another policy if needed by clicking the drop down and changing.
  7. The route of the claim will be defaulted from the Default Electronic option that was selected in the master Insurance Company setup. If Default Electronic was checked at the Insurance Company level, electronic claim submission will default here. If Default electronic was NOT checked, the default claim submission method will be paper. However, the claim route can be changed from the default at any time.
  8. If there is a Secondary Insurance policy for the patient, it will be listed here. The policy can be changed/switched to another policy if needed by clicking the drop down and changing.
  9. If submitting an electronic claim for Primary and Secondary, and the claim is being sent to Gateway EDI, Gateway will send the secondary electronically, if possible. If you need to generate a secondary claim directly out of SOAPware without going through TriZetto, the claim will be sent as a paper claim.
  10. Post the visit to the ledger, when finalized. If a claim is generated, it can be viewed in the patient's Claims tab, as well as in the SOAPware Claims Manager for scrubbing and further processing. Once the visit has been posted, the Post Superbill task will be marked as completed on the user's task list.