1. 5
Working with Cases

2. Learning Outcomes When you finish this chapter, you will be able to:
5-2
When you finish this chapter, you will be able to:
5.1 Describe when it is necessary to create a new case in Medisoft.
5.2 List the eleven tabs in the Case dialog box.
5.3 Review the information contained in the Personal tab and the Account tab.
5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
5.5 Describe the information contained in the Diagnosis tab and the Condition tab in Medisoft.

3. Learning Outcomes (Continued)
5-3
When you finish this chapter, you will be able to:
5.6 Review the purpose of the Miscellaneous, Comment, and EDI tabs in Medisoft.
5.7 Describe how to edit information in a case.

4. Key Terms 5-4 capitated plan case chart primary insurance carrier
record of treatment and progress
referring provider
sponsor
Teaching Notes:
Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.
Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.

5. 5.1 Understanding Cases
5-5
In Medisoft, a case is a grouping of transactions that share a common element
Represent services and treatments the physician provided during a visit
New cases are set up when:
A patient has two or more unrelated conditions
Changes in a patient’s insurance occur
A patient is injured at work and is treated under Worker’s Compensation insurance
Learning Outcome: 5.1 Describe when it is necessary to create a new case in Medisoft.
Pages:
Teaching Notes:
It is the patient’s medical condition that determines whether one or more cases is needed, since each different medical condition requires its own case.
Examples: a chronic (long-lasting and recurrent) condition such as diabetes, charges for all visits related to diabetes are stored in one case. If the same patient also has hypertension, all visits for treatment of hypertension are stored in a different case for hypertension.
A patient may require more than one case per office visit if treatment is provided for two or more unrelated conditions. This does not happen very often because offices prefer to only see a patient for one condition per visit due to complications with filing the insurance.
It is very important to be certain you are working in the correct case. Failure to do so can result in the delay or denial of payment of services.

6. 5.2 Navigating Cases in Medisoft
5-6
Information about a patient’s medical conditions and treatments is stored in the Case dialog box
The Case command buttons are:
Edit Case
New Case
Delete Case
Copy Case
Print Grid
Quick Entry
Close
Learning Outcome: 5.2 List the eleven tabs in the Case dialog box.
Pages:
Teaching Notes:
The information about a patient’s medical conditions and treatments, including the diagnosis, procedures, provider, and insurance plan is stored in the Case dialog box.
Patient List dialog box is used to access the Case dialog box
Edit Case-add, delete, or change information in an existing case
New Case-creates a new case
Delete Case-deletes a case from the system if the case has no open transactions, use with caution, once deleted, information cannot be retrieved
Copy Case-copies all the information from an existing case into a new case. Makes it unnecessary to reenter the information in all eleven tabs. Useful when creating a new case for a patient who already has a case in the system.
Print Grid-elect or deselect columns of information for printing purposes
Quick Entry-used in practices that customize the way patient data are entered
Close-closes the Patient List dialog box

7. 5.2 Navigating Cases in Medisoft (Continued)
5-7
Eleven tabs of the Case dialog box:
Personal
Account
Diagnosis
Policy 1
Policy 2
Policy 3
Condition
Miscellaneous
Medicaid and Tricare
Comment
EDI
Learning Outcome: 5.2 List the eleven tabs in the Case dialog box.
Pages:
Teaching Notes:
Information required to complete the eleven tabs comes from documents found in a patient’s chart. Includes new patient information form, record of treatment and progress, the encounter form. Which will be found in the source documents in this text.

8. 5.2 Navigating Cases in Medisoft (Continued)
5-8
Case dialog box
Learning Outcome: 5.2 List the eleven tabs in the Case dialog box.
Pages:

9. 5.2 Navigating Cases in Medisoft (Continued)
5-9
A chart is a folder that contains all records pertaining to a patient
Information is used to complete the Case dialog box
A record of treatment and progress is a physician’s notes about a patient’s condition and diagnosis
Learning Outcome: 5.2 List the eleven tabs in the Case dialog box.
Pages:

10. 5.3 Entering Patient and Account Information
5-10
The Personal tab contains basic information about a patient and his or her employment
Personal tab
Learning Outcome: 5.3 Review the information contained in the Personal tab and the Account tab.
Pages:
Teaching Notes:
When entering information use the tab as you navigate through the dialog box.
Information found on the patient information sheet will be in the source documents in this text.
Case Number a sequential number can be assigned by Medisoft. To avoid confusion, case numbers are unique; no two patients ever have the same case number. In this text we will assign numbers as directed in Chapter 4.
Case Closed marked by placing a check mark in the Case Closed box. Closing indicates that no more data will be entered into the case. Examples of when to close a case: Policies vary from practice to practice, when a patient changes insurance carriers, has recovered completely from a condition (such as the flu), or is no longer a patient at the practice.
Description indicates a patient’s complaint, or reason for seeing a physician. Examples of entries are sore throat, stomach pains, dog bite, and accident at work.
Cash Case patient is paying cash and has no insurance coverage.
Global Coverage Until These fees include reimbursement for services performed at different times by the same provider (or group) when performed in conjunction with one medical procedure or episode of care. For example, preoperative, intraoperative, and postoperative services are included in the single payment for a global surgical procedure.
Print Patient Statement automatically printed when statements for the practice are printed.
Guarantor name of the person responsible for paying the bill.
Marital Status indicate a patient’s marital status: Divorced, Legally separated, Married, Single, Unknown, or Widowed.
Student Status indicates a full-time student, a part-time student, or a nonstudent.
Employer default employer information that has been entered in the Patient/Guarantor dialog box.
Status employment status as recorded in the Patient/Guarantor dialog box. Options are Full-time, Not employed, Part-time, Retired, and Unknown.
Retirement Date can be entered in the Retirement Date box, or it can be selected from the pop-up calendar that appears when the triangle button to the right of the box is clicked.
Work Phone patient’s work phone number.
Location a specific work location, such as “Fifth Avenue Branch”
Extension work phone extension.
Complete Exercise 5-1.

11. 5.3 Entering Patient and Account Information (Continued)
5-11
The Account tab includes information on a patient’s assigned provider, referring provider, and referral source
Account tab
Learning Outcome: 5.3 Review the information contained in the Personal tab and the Account tab.
Pages:
Teaching Notes:
When entering information, use the tab as you navigate through the dialog box.
Information is found on the patient information form.
Assigned Provider automatically filled in with the code number and name of the assigned provider.
Referring Provider a physician who recommends that a patient see a specific other physician. The name of the physician who referred the patient to the practice.
Supervising Provider When the provider rendering services is being supervised by a physician, the supervising physician’s information is included on the claim.
Referral Source If known, the source of a patient’s referral.
Attorney used for accident cases. If a patient has an attorney, the name of the attorney should be selected from the drop-down list.
Facility lists the place where a patient is receiving treatment.
Case Billing Code a one- or two- character box used by some practices to classify and sort patients by insurance
carrier, diagnosis, billing cycle, or other kinds of information.
Price Code determines which set of fees is used when entering transactions for this case.
Other Arrangements If a special arrangement is made for billing, indicated here.
Treatment Authorized Through if the insurance carrier has authorized treatment only through a certain date.
Visit Series used primarily by psychotherapy practices and chiropractors.
Do exercise 5-2

12. 5.3 Entering Patient and Account Information (Continued)
5-12
A referring provider is a physician who recommends that a patient see a specific other physician
The Referring Provider box of the Account tab contains the name of the physician who referred the patient
Learning Outcome: 5.3 Review the information contained in the Personal tab and the Account tab.
Pages:

13. 5.4 Entering Insurance Information
5-13
The primary insurance carrier is the first carrier to whom claims are submitted
There may also be a secondary carrier or a tertiary carrier
Only primary claims can be submitted electronically
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:

14. 5.4 Entering Insurance Information (Continued)
5-14
The Policy 1 tab records information about a patient’s primary insurance carrier and coverage
Policy 1 tab
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:
Teaching Notes:
Information found on patient information form. When entering information use the tab as you navigate through the dialog box.
Insurance 1 lists the code number and name of the insurance carrier.
Policy Holder 1 lists the person who is the insured under a particular policy. If the patient is a child covered under his or her parent’s insurance plan, the parent’s chart number would be entered in this box.
Relationship to Insured describes a patient’s relationship to the individual listed in the Policy Holder 1 box.
Policy Number policy number is entered in the Policy Number box
Group Number The group number for a patient’s policy.
Policy Dates—Start/End The date a patient’s insurance policy went into effect is entered in the Policy Dates—Start box. the date on which coverage terminated is entered in the Policy Dates—End box.
Claim Number This field is used on property, casualty, and auto claims. The number is assigned by the property and casualty payer, usually during eligibility determinations.
Assignment of Benefits/Accept Assignment indicates that the provider accepts payment directly from the insurance carrier.
Capitated Plan In a capitated plan, prepayments are made to the physician from a managed care company to cover the physician’s services to a plan member for a specified period of time.
Copayment Amount The dollar amount of a patient’s copayment per
visit is entered in the Copayment Amount box.
Annual Deductible The dollar amount of the insured’s insurance
plan deductible is entered in this box.
Deductible Met This box is checked if the patient has met the deductible
for the current year.
Treatment Authorization used to record the treatment authorization code from an insurance company for UB-04 claims.
Insurance Coverage Percents by Service Classification The percentage of fees that an insurance carrier covers is entered in the Insurance Coverage Percents by Service Classification box. Example, a plan may pay 80 percent of necessary medical procedures, 100 percent of lab work, and 50 percent of outpatient mental health charges.

15. 5.4 Entering Insurance Information (Continued)
5-15
In a capitated plan, payments are made to the physician from a managed care company for patients who select the physician as their primary care provider, regardless of whether the patients visit the physician
A check mark in the Capitated Plan box of the Policy 1 tab indicates an insurance plan is capitated
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:
Teaching Notes:
Reinforce this concept. Make sure students understand how it is different from HMO information.

16. 5.4 Entering Insurance Information (Continued)
5-16
The Policy 2 tab records information about a patient’s secondary insurance carrier and coverage
Policy 2 tab
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:
Teaching Notes:
Information found on patient information form. When entering information use the tab as you navigate through the dialog box.
Primary carrier has to pay first before submitting to secondary. The secondary carrier must have access to the remittance advice of the primary carrier to see what has already been paid on the claim. Delayed secondary billing may be set up so a claim is not created for the secondary carrier until a response has been received from the primary carrier.
The boxes in the Policy 2 tab are the same as those in the Policy 1 tab, with a few exceptions. The Copayment Amount, Capitated Plan, Annual Deductible, and Deductible Met boxes are only in the Policy 1 tab. Only the Policy 2 tab has a Crossover Claim box used when a patient has Medicare as the primary carrier and Medicaid as the secondary carrier.
Do Exercise 5-3

17. 5.4 Entering Insurance Information (Continued)
5-17
The Policy 3 tab records information about a patient’s tertiary insurance carrier and coverage
Policy 3 tab
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:

18. 5.4 Entering Insurance Information (Continued)
5-18
The Medicaid and Tricare tab is used to enter additional information about the government programs
Medicaid and
Tricare tab
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:
Teaching Notes:
Medicaid
EPSDT EPSDT stands for Early and Periodic Screening, Diagnosis, and Treatment. Medicaid program for patients under the age of twenty-one who need screening and diagnostic services to determine physical or mental problems as well as treatment for conditions discovered. includes well-baby checkup examinations.
Family Planning A specifies that a patient’s condition is related to Medicaid family planning services.
Resubmission Number For claims being resubmitted to Medicaid, the resubmission number is entered in this box.
Original Reference For claims being resubmitted to Medicaid, the original reference number is recorded
Service Authorization Exception Code required on some Medicaid claims. If a service authorization code was not obtained before seeing the patient, select one of the following codes:
1. Immediate/Urgent Care
2. Services Rendered in a Retroactive Period
3. Emergency Care
4. Client as Temporary Medicaid
5. Request from County for Second Opinion to Recipient Can Work
6. Request for Override Pending
7. Special Handling
TRICARE government insurance program serves spouses and children of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members (Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and NOAA, the National Oceanic and Atmospheric Administration).
Non-Availability Indicator specifies whether a nonavailability (NA) statement is required.
Branch of Service branch of service: Army, Air Force, Marines, Navy, Coast Guard,
Public Health Service, NOAA, and ChampVA.
Sponsor Status The sponsor is the active-duty service member.
Special Program for special TRICARE programs.
Sponsor Grade The two-character sponsor grade.
Effective Dates The start date of the TRICARE policy is entered in the Effective Dates—Start box. If there is an end date, it is entered in the Effective

19. 5.4 Entering Insurance Information (Continued)
5-19
In TRICARE, a sponsor is the active-duty service member
Sponsors’ family members are covered by the TRICARE insurance plan
Learning Outcome: 5.4 Discuss the information recorded in the Policy 1,2,3 and Medicaid and TRICARE tabs in Medisoft.
Pages:

20. 5.5 Entering Health Information
5-20
The Diagnosis tab contains a patient’s diagnosis, information about allergies, and electronic media claim (EDI) notes
Diagnosis tab
Learning Outcome: 5.5 Describe the information contained in the Diagnosis tab and the Condition tab in Medisoft.
Pages:
Teaching Notes:
Principal Diagnosis and Default Diagnosis 2, 3, and 4 selected from the drop-down list of diagnoses. If a patient has more than one diagnosis for the same condition, the primary diagnosis is entered in the Principal Diagnosis field. Can add up to 8.
Allergies and Notes entered here drugs or seasonal or any other pertinent information.
EDI Notes If claims require special handling when submitted electronically, notes about the procedure, such as an explanation about the charges for supplies.
EDI Report The Report Type Code is a two-character code that indicates the title or contents of a document, report, or supporting item sent with electronic claims. The Report Transmission Code is a two character code that defines the timing, transmission method, or format by which reports are sent with electronic claims. The value entered in the Attachment Control Number field is a unique reference number up to seven digits long.
Complete exercise 5-4

21. 5.5 Entering Health Information (Continued)
5-21
The Condition tab stores data about a patient’s illness, accident, disability, and hospitalization
Condition tab
Learning Outcome: 5.5 Describe the information contained in the Diagnosis tab and the Condition tab in Medisoft.
Pages:
Teaching Notes:
Injury/Illness/LMP Date The date of a patient’s injury, illness, or last menstrual period (LMP)
Illness Indicator specifies whether a patient’s condition is an illness, a last menstrual period in the case of a pregnancy, or an injury.
First Consultation Date The date of a patient’s first visit for a particular condition
Date Similar Symptoms If a patient has had similar symptoms in the past, enter the date
Same/Similar Symptoms indicates that a patient has had the same or similar symptoms in the past.
Employment Related the illness or accident is in some way related to a patient’s employment.
Emergency If a patient sees the provider on an emergency visit.
Accident—Related To The Accident—Related To box indicates whether a patient’s condition is related to an accident. The State and Nature Of boxes should also be completed.
Accident—State The abbreviation for the state in which the accident occurred.
Accident—Nature Of additional information about the type of accident.
Last X-ray Date The date of the last X-rays for the current condition.
Death/Status The Death/Status box indicates a patient’s condition according to the Karnofsky Performance Status Scale. If information is not provided by the physician, the box should be left blank
Dates—Unable to Work If a patient is unable to work, the dates of the absence from work are listed.
Dates—Total Disability If a patient is totally disabled, the dates of the total disability.
Dates—Partial Disability If a patient is partially disabled, the dates of the partial disability.
Dates—Hospitalization If a patient is hospitalized, the dates of the hospitalization.
Workers’ Compensation—Return to Work Indicator If a patient has been out of work on workers’ compensation, the patient’s return to work status is selected from the drop-down list of choices.
Workers’ Compensation—Percent of Disability indicates a patient’s percentage of disability upon returning to work.
Last Worked Date The last day the patient worked.
Pregnant checked if a woman is pregnant.
Estimated Date of Birth enter the date the baby is due.
Date Assumed Care This field is used when providers share postoperative care.
Date Relinquished Care This field is used when providers share postoperative care.
Complete exercise 5-5

22. 5.6 Entering Other Information
5-22
The Miscellaneous tab records a variety of miscellaneous information about the patient and his or her treatment
Miscellaneous tab
Learning Outcome: 5.6 Review the purpose of the Miscellaneous, Comment, and EDI tabs in Medisoft.
Pages:
Teaching Notes:
Outside Lab Work the lab work was performed by a lab other than the physician’s office.
Lab Charges The charges for lab work, whether performed inside or outside the practice.
Local Use A and B used to record information specific to the local office.
Indicator. Patients might be categorized according to the primary diagnosis. Services might be divided into such categories as lab work, consultations, and hospital visits.
Referral Date date of the referral
Prescription Date required for hearing and vision claims.
Prior Authorization Number Before some services are performed, prior authorization must be obtained from the appropriate insurance carrier.
Extra 1, 2, 3, and 4 The Extra 1, 2, 3, and 4 boxes are used for different purposes depending on the medical practice.
Outside Primary Care Provider If a patient is covered by a managed care plan and the patient’s primary care provider is outside the medical practice, the name of the provider is selected from the drop-down list in this box.
Date Last Seen The Date Last Seen box lists the date a patient was last seen by the outside primary care provider.

23. 5.6 Entering Other Information (Continued)
5-23
The Comment tab is used to enter case notes
Comment tab
Learning Outcome: 5.6 Review the purpose of the Miscellaneous, Comment, and EDI tabs in Medisoft.
Pages:
Teaching Notes:
Used to enter case notes and will print on statements if statements are formatted to include case comments.

24. 5.6 Entering Other Information (Continued)
5-24
The EDI tab is used to enter information for electronic claims specific to the case
EDI tab
Learning Outcome: 5.6 Review the purpose of the Miscellaneous, Comment, and EDI tabs in Medisoft.
Pages:
Teaching Notes:
Care Plan Oversight # If a physician is billing for home health and hospice care plan oversight (CPO), enter number.
Assignment Indicator The entry in this field is the assignment indicator for this case. Valid codes are
A Assigned
B Assignment accepted on clinical lab services only
C Not assigned
P Patient refuses to assign benefits
Hospice Number If a physician is billing for hospice care.
Insurance Type Code The type of insurance that the patient has is selected in the Insurance Type Code field. Required when sending Medicare secondary claims.
Clinical Laboratory Improvement Act (CLIA) number must be included in the claim. Assigned to labs and required on all laboratory claims billed to Medicare.
Timely Filing Indicator If a response to a request for information from an insurance carrier was delayed, the reason for the delay is entered.
Mammography Certification provider’s or facility’s mammography certification number.
EPSDT Referral Code The patient’s referral code.
Medicaid Referral Access # The referring physician’s Medicaid referral access number
Homebound If the patient is under homebound care.
Demo Code used when filing claims for this patient under demonstration projects.
IDE Number required when there is an investigational device exemption on the claim. Usually for vision claims.
Vision Claims vision claim entries.
Condition Indicator The code indicator is entered in this field.
Code Category for the vision device.
Certification Code Applies if a certification code is applicable.
Home Health Claims If a provider submits home health claims.
Total Visits Rendered indicates the total number of visits.
Discipline Type Code The provider’s discipline type code.
Total Visits Projected total number of visits projected.
Ship/Delivery Pattern Code Enter the pattern code for the home visits.
Number of Visits The total number of visits.
Ship/Delivery Time Code Records the time code for the home visits.
Duration The duration of the home health visits.
Frequency Period The frequency period for the home visits.
Number of Units Contains the number of units for the home visits.
Frequency Count The frequency count for the home visits.

25. 5.7 Editing Case Information
5-25
To edit case information:
Select a case
Click the Edit Case button
Or open a case for editing by double-clicking directly on the case line in the right half of the dialog box
Learning Outcome: 5.7 Describe how to edit information in a case.
Pages:
Teaching Notes:
Complete Exercise 5-6
Review the reasons you would want to edit a patient’s case.