About the Finalize tab
The Finalize tab in Medical Note marks the endpoint of your documentation process, offering a comprehensive overview of the note contents for any necessary updates before finalization.
Note details
The Note Details section provides information about the service rendered. The service code, program, and note type provide context for the encounter while the reason for visit and visit notes provide insight into the patient's purpose for the visit and visit details. The location for the service affects the CPT codes recommendations, which are based on the place of service. For example, an 'office' location corresponds to 'office or other outpatient location'. Billing details such as primary and additional diagnoses ensure compliance and accurately reflect the patient's condition and services provided.
CPT selection
The CPT selection feature provides code recommendations based on medical decision making (MDM) or encounter time. The total encounter time, including the face-to-face and non-face-to-face time entered, guides the time-based code recommendations. Select Calculate CPT to see document-based and time-based recommendations. CPT tiles display MDM type, client type, and service setting with corresponding codes. Providers can accept recommendations or override them in the CPT Code Selected field. In some cases, the CPT recommendation feature may be disabled for straightforward services like psychiatric evaluations or wellness visits where a single CPT code is typically billed, maintaining an efficient workflow tailored to your needs.
Add-on services
Add-on services are supplemental services for providers to bill for care they provide beyond the primary service. The Add-on Services section appears based on the selected CPT code, as system configuration determines whether these services can be applied to the chosen CPT code. You can include multiple add-on services, each with its own duration and documentation requirements. For example, if an add-on service such as interactive complexity is selected, the system may prompt you to fulfill additional requirements before adding the service.
Note summary
The note summary is generated before finalizing the note, giving you the opportunity to make documentation adjustments before finalization. Selecting Generate Note condenses intake and examination details into a concise summary that captures relevant information. This streamlined process improves efficiency and accuracy in patient care and recordkeeping.