Assessment, Superbill & Referral
Three tabs handle the "close out" side of an exam: Assessment (what's wrong), Super (what the patient is billed for), and Referral (who to send them to).
Assessment tab
Where the doctor's diagnoses go. This is what billing pulls into claims.
- Assessment & Diagnoses — add ICD-10 codes with descriptions. Type a code or search by name.
- Plan / Note — what the doctor is doing about each diagnosis (Rx change, follow-up in 6 months, referral, etc.).
- PQRS — Physician Quality Reporting System measures — the quality-of-care ticks required for some payers.
Super tab (Superbill)
The superbill is the doctor's summary handed to billing. It lists:
- Diagnoses — pulled from the Assessment tab.
- Procedures — CPT codes for what was done (comprehensive exam, refraction, VF, fundus photo, etc.).
- Invoice items — line items with charges that go on the patient's invoice.
Anything the doctor codes here shows up on the claim when billing generates it later.
Referral tab
Send the patient to another doctor and print/email a referral letter.
- Doctor selection — pick a specialist from your referral list (retina, glaucoma, oculoplastics, etc.).
- Addressing — where the letter goes.
- Tests to include — tick which findings/tests from THIS exam to include in the letter (VF, fundus photo, IOP history, etc.).
- Referral form — free-text on why you're referring and what you'd like the specialist to look at.
Once completed, print or email the referral. A copy is saved in the patient's Files.
Related
- Exam — overview
- Refraction
- Claims & Billing (coming)