Completing Outpatient
Encounters
A step by step visual
guide
What you will learn
(click on a topic to jump to that page or section)
The importance of timely, accurate
completion of Encounter forms for
outpatient treatment
Definition of a complete Encounter
PLEASE –a mnemonic device!
How to complete an encounter
associated with an appointment
Where to go for additional help
The Importance of Encounters
Encounters are the means of reporting
outpatient workload
Funding is based on workload reported to
Austin –National Pt Care Database (NPCD)
–Nationally –the facility and VISN budget
–Locally –VISN and facility funding to the
department and program level
Workload credit in Austin = money for facility
A Complete Encounter:
MUST INCLUDE
–Primary Provider (one)
–Primary Diagnosis (one)
–Primary CPT code for
most invasive procedure
performed (or Evaluation
and Management Code)
–Responses to applicable
pt classification
questions
MUST BE
ASSOCIATED WITH
THE CORRECT
“LOCATION” or CLINIC
MAY INCLUDE
–Secondary Provider(s)
–Secondary Diagnoses
–Secondary CPT Codes
Patient Classification Questions
The provider must respond to each
question that appears for the patient -
Is this encounter related to the
patient’s:
–Service Connected injury/illness
–Agent Orange exposure
–Ionizing Radiation exposure
–Military Sexual Trauma (MST)
–Environmental Contaminant exposure
–Head and Neck Cancer
STOP
Missing Patient Classification responses
are the #1 reason encounters cannot
transmit to Austin for workload credit!
Logged in to CPRS –select new patient
Click the File Tab then click
File/Select New Patient
Aadadkwr,Robert
Aafsdkjrek,Thomas
Aberwweuna,Bassil
Adfaseasc,Jose
Adjdakd,William
Adka,Eugene
Affwee,Roger
Afwert,David
Afzemm,Eric
Agwers,James
Ahhmen,Zeus
Aqerkj,Achilles
Baaqp,Lionel L.
Baxrem,Kareem A.
Bakejrw,Lloyd
Balmera,Timothy
Berlklaa,Esculapius
Bobkca,Michael P.
Bozzip,Lester J.
Bubklar,Harry
Cawep,Donald S.
Clump,Andre
Cwimt,Ronald
Enter name or SSN or last initial & last 4 digits of SSN
Then
Click
“OK”
Select the Provider & Location for Current Activities
Click on this button to get the
location dialog box
Select the Provider & Location for Current Activities
Enter the name of the provider
Select the appropriate
clinic appointment
Select the Provider & Location for Current Activities
Official workload credit for your
program is tied to your particular
clinics.
This is not a random guess!
With provider and location
selected, click the “OK” button
If you are unsure which clinic to use, please contact
your service/program’s encounter resource person for
immediate assistance..
If the pt does not have a pre-made appointment:
STOP
Are you
certain?
Clinic names can be similar, check all
possibilities
If the patient did not have a pre-made
appointment, click on the “New Visit” tab
If the pt does not have a pre-made appointment:
If you are absolutely
sure that you haven’t
missed an existing clinic
appointment, click on
the New Visit Tab
Select an appropriate
visit location, one that
will send workload credit
for your program.
Time = NOW unless you
override it
Seriously, if you select the
incorrect clinic, you lose
credit for work you’ve done
Click on the Encounter button
Do not use the
modifier box
Complete the Visit Type details –Eval & Mgt Codes
Select
Type of
Visit
Then
select
appropriate
Section
Name
TIP
If a
procedure clinic,
you do not need to use
the evaluation & management
codes - code only the
procedure
itself
Don’t know which code
is appropriate?
Coding Supervisor
can help:
ext. 5010
Complete the Visit Type details –patient classification
Lack of Patient classification information will
prevent the encounter from being transmitted to Austin
as official workload.
If Classifications appear here, you
must respond to EACH of them.
They only appear if pertinent to the patient.
Patient’s service connected
condition will appear here,
if applicable
Complete the Visit Type details –Providers (& Primary)
Designate primary by clicking on provider
highlight the name under “current provider
for this encounter”, (even if you are the only
provider on the encounter). Then click the
Primary button
Select the provider(s) name from “available
providers” list, then click the “add” button
NOT YET
Move to next tab - Diagnoses
Click on
the
Diagnoses
tab to
continue
Must have
-Primary Diagnosis
-Primary Provider
-CPT Code
(Procedure OR E&M)
Add Diagnoses details
The default view
is the patient’s
problem list
You may select a
diagnosis from the
list if treated
during THIS
encounter
Otherwise, select
a specialty to
narrow the focus
Add Diagnoses details - select specialty and diagnosis
The first diagnosis will default as primary
to change primary, highlight and use this key
Add Diagnoses details
Click to
add
procedures
performed
during this
encounter
Note the list of diagnoses with
ONE primarydesignated
HINT
If using a
procedure clinic,
be sure to code the procedure
performed by you
during this
encounter
Add Procedure details
The default procedure list is
from your clinic’s assigned
encounter form. You may select
other procedures by clicking the
button “Other Procedures”.
Select the procedures completed by
THIS clinic team in THIS encounter
Immunazations
Click on the appropriate tab record pertinent
Vital signs, Immunizations,Pt Education,
Health Factors and Special Exams
Please contact the Clinical Applications
Coordinator (CAC) assigned to your
service for more information on these
optional items
When you have completed the encounter
information, click “OK”.
Complete and Sign the Note
Select an appropriate note title
Complete the text of the note
Helpful reminders
–Use the Encounter information to remind you
what procedures and diagnoses to include.
–Mismatch of encounter information to progress
note details can lead to charges of insurance
fraud
Sign Note after note & encounter are
completed
Notice the tabs at the base of the cover sheet
Click on
“Notes”
Tab
This is the Notes view
Select an appropriate note title for your encounter/visit
Note title selection
should be logical
AND
in compliance with
your service or
program’s
established
processes
Selected appropriate note title, click “OK” button.
Click
OK
Here’s an example of a blank progress note
Note the
Encounter
information
Use this as a
reminder for the
contents of the
patient’s clinic
note
!!!!WARNING!!!!
If no encounter information
is displayed, an encounter
has not yet been associated
with this clinic location
or appointment.
Complete encounter details
before signing the note.
When you have completed your
encounter and clinic note,
use the ACTION TAB to sign the
note
The final steps!
Exit CPRS after completing encounter and note
You have completed your Encounter!
The focus of this presentation is the correct
completion of outpatient encounters
The expectation/new standard is to complete
the encounter as soon as possible after the
patient leaves the clinic appointment.
Completion is tracked by stop code and
clinic in the weekly Stoplight Report.
