IMA Guide: Epic Visit Navigator

Edit

1. CareEverywhere

Query

2. Plan Tab

➢ Problem List

Delete erroneous problemsMerge duplicate problemsResolve problems that are no longer relevantAdd missing problemsDocument A&P under “Create Current Assessment & Plan Note”Click + to Add problems to the visit diagnoses if addressed this visit

3. Medications Tab

Reconcile outside medications after you have queried CareEverywhereConfirm listed dosagesDelete medications the patient is not taking+ Patient-Reported for medications / supplements taken but not prescribed through MSH EpicRefills: 90 day supply x 3 refills for medications prescribed by primary care.

Do not refill medications prescribed by specialists, e.g. glaucoma medications.

Verify pharmacy with patient (Listed at the bottom)Click Mark as Reviewed

4. Allergies Tab

Allergies: click Mark as Reviewed

5. History Tab

Medical History: update for NEW patientsSurgical History: update for NEW patientsFamily History: update for NEW patientsSubstance Use: updateSexual Activity: updateSocial Documentation: updateTobacco History: updateTobacco Screening: update

6. Health Maintenance

Update

7. Visit Diagnoses

Add any additional diagnoses needed here, rather than from Problem List.

These will be diagnoses that do not belong on the Problem List, e.g. Annual physical exam, Colorectal Cancer Screening, or acute problems likeViral URI that are likely to resolve quickly.

Delete diagnoses that you do not intend to documentSpecify all diagnoses fully.

No diagnosis can be left “unspecified.”

Delete any Z00.00 code, e.g. Healthcare Maintenance, if it is not an annual visit.

This code cannot be listed ANYWHERE unless it is an annual visit.

Select a primary diagnosis by clicking the diamond and then dragging that diagnosis to the top.

For annuals: Annual physical exam Z00.00
For all other visits, the primary diagnosis cannot be any code that starts with a Z

8. Orders

Associate Signed Orders (all must have an association)

9. Notes Tab

.IMASTANDARDIZEDREVISIT/NEW/VIDEO

10. Level of Service

LOS

ANNUAL

WITHOUT Medicare: NEW 99395-97 or ESTABLISHED 99385-87.
WITH Medicare: G0438-G0439, but we recommend that residents do not bill this as the documentation requirements are very specific.

NOT an annual, i.e. E/M (Evaluation/Management)

99213 if your attending did NOT see the patient OR was not complex.
99214 if your attending SAW the patient AND the visit was moderately complex.
99215 if your attending SAW the patient AND the visit was very complex.

Modifier: for RESIDENTS only

GC: your attending SAW the patient. For Annuals for patients without Medicare (i.e. 99385-87 & 99395-97), 99214, and 99215, your attending needs to have seen the patient.
GE: your attending did NOT see the patient, e.g. for 99213 or G0439.