1 View a new clinical document; for instructions, see View New Clinical Documents.
2 In the Diagnostic Description column, click Add.
3 In the list of code types, click ICD-9, CPT® & HCPCS level II, LOINC only, or SNOMED only to indicate the type of code or description you are entering.
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Notes: • CPT & HCPCS level II is selected by default. • If you choose to search for an ICD or CPT/HCPCS code or description, related SNOMED descriptions for the code or description entered display (if available). |
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CPT ® copyright 2016 American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. |
4 In the Procedure box, type three or more characters of the code or description you want to add for the document.
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Notes: • You can also add a free text description that is not in the database. To do so, type the description (up to 255 characters). • These procedure codes are used for reporting on the following quality measures: CMS125 / NQF0031, NQF0033, CMS166 / NQF0052, NQF0081, and NQF0083 When reporting on CMS125 / NQF0031 and CMS166 / NQF0052 you must use LOINC. |
5 Click the appropriate item in the list of matches. If necessary, click View more results to view additional items in the list.
6 In the Result Value box, type a numerical value.
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Notes: • This field does not support alphanumeric characters. Only numerics are supported. • Result values are used for reporting on the following quality measures: NQF0081, and NQF0083. |
7 In the Comments box, type any notes you want to associate with the diagnostic description.
8 Click Save.