Role Required: Clinician (for assigned patients), Clinical Administrator, Practice Scheduler, or Practice Biller
Occasionally, the service you render may not be the one you initially scheduled. A session may run long, allowing you to bill for a full 60-minute session instead of the scheduled 45-minute session, or perhaps you accidentally scheduled a session when in reality it was an intake.
There are numerous circumstances in which you may need to change a service, or CPT, code. The process differs according to whether or not the corresponding note was completed and whether or not you need to also change the service type.
Change a Service Code Before the Note Is Completed
- Click Patients > Patient name > Patient Billing tab
- In the table under Search Billing Transactions, click on the date of service containing the service code you wish to change.
- A dialog with additional details about the date of service appears. Click the Appointment tab.
- Select the correct service code from the Service Code dropdown. If the correct service code isn't available, select the correct service type from the Appointment Type dropdown.
- Click the Save Changes button.
Change a Service Code of the Same Service Type After the Note Is Completed
Note: Only the Clinician who completed the note should complete these steps.
- Click Patients > Patient name > Documents tab
-
In the section labeled Notes and Documents for this Patient, find the note for the date of service containing the service code you wish to change. Click the Edit icon to the right of that note.
- Click anywhere on the note header to edit.
- In the About this Note dialog that appears, select the correct service code from the Service Code dropdown.
- Click the Update Note Header button.
- Electronically sign the note and click the Save Changes to Note button.
Change a Service Code of a Different Service Type After the Note Is Completed
Note: You must delete the existing note to change a service code of a different service type. Only a Clinical Administrator or users with the role of both Practice Administrator and Clinician (for assigned patients only) can delete notes. The Clinician who completed the original note should complete the remaining steps.
- Click Patients > Patient name > Documents tab
- In the section labeled Notes and Documents for this Patient, find the note for the date of service containing the service code you wish to change. Click the Download
icon for that note.
- Verify that the note downloaded successfully.
- Return to the Documents tab for the client. In the section labeled Notes and Documents for this Patient, find the note that you downloaded. Click the document title to open the note.
- Click the Delete Note link in the bottom right corner of the note.
- A warning dialog will appear to alert you that the note will be permanently deleted. Click the Delete button.
- Follow the instructions above to change a service code before the note has been completed.
- Create a new note for the appointment and copy and paste the information from the downloaded note into the new note.