How to Add or Edit an Immunization
When you choose Immunization under Update Encounter, you will also be prompted to enter the Provider, Series, Reaction, Repeat Contraindicated, ordering and administered times, and comments.
Immunizations are mapped to CPT codes. When an Immunization is entered, the user will be prompted for diagnoses which are associated with the mapped CPT code. If the diagnoses have not already appeared in the encounter, the user will be prompted for additional information to qualify the diagnosis such as modifiers, comments and SC/EI classifications.
NOTE: A Clinical Coordinator can change the items or categories available to choose from for Immunization through the PCE Table Maintenance Menu. To help define the Immunization list, check with your Coordinator.
Steps to add an Immunization
1. Select UE from the PCE Appointment List screen.
2. Select IM from the PCE Update Encounter screen.
PCEoutpatient,two 000-00-0002 Clinic: CARDIOLOGY
Encounter Date 07/22/96 11:08 Clinic Stop: 303 CARDIOLOGY
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
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) XA Exam
CP CPT (Procedure) HF Health Factors
Select Action: Quit//im Immunization [ENTER]
--- Immunization ---
Patient's Service Connection and Rated Disabilities:
SC Percent: 100%
Rated Disabilities: TRAUMATIC ARTHRITIS (10%-SC)
DIABETES MELLITUS (0%-SC)
36PCE V. 1.0 User ManualAugust 1996