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Using PCE

How to Add or Edit a CPT (Procedure)

When you choose CPT (Procedure) under Update Encounter, you will also be prompted to enter the Provider Narrative, Quantity, Diagnosis, Principal Procedure, Encounter Provider, and comments. With functionality put in place by the Code Set Versioning project, only CPT Codes that are active for the encounter date and time will be available.

One Primary diagnosis and up to seven Secondary diagnoses may be associated with a procedure as clinical indicators. The example below shows the association as it appears on the PCE Encounter Profile screen.

   CPT Code:  76003     NEEDLE LOCALIZATION BY X-RAY                           

   Order Reference:  13559999                                                  

   Provider Narrative:  RENAL CYST ABLATION                                    

   Quantity:  1                                                                

   Ordering Provider:  RNMprovider,one                                         

   Encounter Provider:  RNMprovider,two                                        

   Primary Diagnosis:  246.2     CYST OF THYROID                               

   1st Secondary Diagnosis:  362.54     MACULAR CYST OR HOLE                   

   2nd Secondary Diagnosis:  364.63     PRIMARY CYST PARS PLANA                

   3rd Secondary Diagnosis:  364.64     EXUDAT CYST PARS PLANA                 

   4th Secondary Diagnosis:  383.31     POSTMASTOID MUCOSAL CYST               

   5th Secondary Diagnosis:  478.26     CYST PHARYNX/NASOPHARYNX  

   6th Secondary Diagnosis:  522.8     RADICULAR CYST                          

   7th Secondary Diagnosis:  577.2     PANCREAT CYST/PSEUDOCYST

Steps to edit a CPT

1. Select UE from the PCE Appointment List screen.

2. Select CP from the PCE Update Encounter screen.

PCE Update Encounter         Jul 02, 1999 08:24:21       Page:  1 of  1

PCEoutpatient,two    000-00-0002         Clinic:  CARDIOLOGY

Encounter Date  07/99/96  11:08         Clinic Stop:  303  CARDIOLOGY

 1 Encounter Date and Time:  JUL 22, 1996@11:08:14

 2 Provider:  PCEprovider,one    PRIMARY    ATTENDING

 3 ICD9 Code or Diagnosis:  V70.3     MED EXAM NEC-ADMIN PURP

   Provider Narrative:  OTHER GENERAL MEDICAL EXAMINATION FOR

                        ADMINISTRATIVE PURPOSES

   Primary/Secondary Diagnosis:  PRIMARY

 4 CPT Code:  25066     BIOPSY FOREARM SOFT TISSUES

   CPT Modifier: 22   UNUSUAL PROCEDURAL SERVICES

 5 Education Topic:  VA-TOBACCO USE SCREENING

         + Next Screen   - Prev Screen   ?? More Actions

ED  Edit an Item        TR  Treatment           DD  Display Detail

DE  Delete an Item      IM  Immunization        DB  Display Brief

EN  Encounter           PE  Patient Ed          IN  Check Out Interview

PR  Provider            ST  Skin Test           QU  Quit

DX  Diagnosis (ICD 9)   XA  Exam

CP  CPT (Procedure)     HF  Health Factors

32PCE V. 1.0 User ManualAugust 1996

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