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Using PCE

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.

PCE Update Encounter         Jul 25, 1996 08:24:21       Page:  1 of  1

PCEoutpatient,two    000-00-0002         Clinic:  CARDIOLOGY

Encounter Date  07/22/96  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)     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

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