Documentation
Note elements
Choose the medical necessity elements every visit note must carry before it can be signed, and see what payers with their own list add.
Payers expect a visit note to show certain facts, such as when the visit started and ended and the units of every code. Note elements lets your clinic require them, so a note missing one cannot be signed. They apply to daily notes of every discipline.
Choose the elements#
Open Setup > Note elements:
- Required for every payer: the elements every daily note checks.
- Payers with their own list: the payers whose note element lists add elements for visits billed to them, and whether each list holds signing or only warns. Click Edit Payer Lists to change them in Setup > Payer Note Elements, the one place payer lists are kept.
Click Save Changes. Until you save, each discipline uses its own default, listed under the elements; most disciplines start with none.
| Element | Met when |
|---|---|
| Start and end times | The note is written on its visit, which holds the times |
| Duration | The visit has a length |
| Service code and units | The visit has codes, each with its units |
| Place of service | The visit has a place of service |
| Rendering provider and credential | The note's provider has a credential on file |
Disciplines with elements of their own, such as ABA, add a section below with their own lists (see Session note settings).
When a note is missing one#
The checks before signing list each missing element once, with what to fix, and Sign stays unavailable until it is fixed. An element a payer asks for starts with the payer's name; when that payer's list does not hold signing and your clinic's list does not require the element, it shows as a warning instead. Required pick lists are checked the same way.
Permissions#
Anyone with access to Setup can see the page. Changing it needs permission to manage clinical setup.