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SOFP

Reference Manual

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Introduction. 3<= /span>=

Demographics Page. 4<= /span>=

SOFP Encounter Closing Pages. 8<= /span>=

SOFP Encounter Form.. 15<= /span>=

 

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Introduction

 

This manual was developed by eHealthCare System, Inc. to describe changes that were made to our Practice Management System (= PMS) application in accordance with the new Title X requirements for data collec= tion and reporting. 

 

The implementation date for these changes is effective on June 1, 2010.

Demographics Page

=

Figure = 1 - OLD Demographics Page

 

=

Figure<= /span> = 2 - NEW Demographics Page

 =

Demographics Page  Summary= of Changes=

 

   1.      =       Interpreter Needed? Added option

a.   You must provide an answer

b.   Try to capture this data accurately<= o:p>

   2.      =       Family Size/Income:

a.   Repositioned columns

   3.      =       Ind. Monthly Income ($):

a.   Resized column to match like columns=

   4.      =       Family Size & Income:

a.   Changed Family Size/Income labels

   5.      =       Patient Fee (%):<= /b>

a.   Repositioned column

   6.      =       Patient Fee Category:

a.   Added option

b.   Selections are A, B, B2, C, and D

c.    Add to patient’s record manual= ly, or

d.   To have the option automatically populate the patient’s demographics table, add default options to your custom family size and income data, which is located in Administration prog= rams > Preferences > Discount Table

e.   This information will print on your superbill

   7.      =       Ethnicity / Is Patient Hispanic?

a.   Added Unknown option=

b.   Please try to capture this data accurately

   8.      =       Is Patient US Citizen?

a.   Changed label

b.   Added Unknown option=

   9.      =       Mental or Physical Disabilit= ies, Alcohol or Drug Abuse, Patient’s Smoking Status:

a.   Mental or Physical Disabilities column: Changed label

b.   Alcohol or Drug Abuse column: Changed label

c.    What is the Patient’s Smoking Status? Column: Added option

10= .      =       Migrant/Migrant Seasonal Wor= ker:

a.   Changed label

b.   Replaced option “Seasonal” with option “= ;Unknown”

11= .      =       Homeless:

a.   Repositioned column

b.   Changed label

c.    Added “Unknown” opti= on

12= .      =       Stayed Last At?

a.   Repositioned column

b.   Changed label

13= .      =       In-patient Facility:<= /i>

a.   Repositioned column

14= .      =       Hospital Admit and Hospital Discharge:

a.   Repositioned columns

15= .      =       Head of Household Gender:

a.   Repositioned column

16= .      =       Years of Education:

a.   Repositioned column

17= .      =       Extended bottom dividing line

 

SOFP Encounter Closing Pages

=

 =

Figure = 3 - OLD SOFP Encounter Closing Page

Figure 4 - NEW SOFP Encounter Closing P= age 1

Figure 5 - NEW SOFP Encounter Closing P= age 2

 

CHECKING OUT SOFP ENCOUNTERS

 

The new SOFP/FPACT checkout page has chang= ed significantly. Look for these items on the new closing page:

 

·        Demographics and patient contact information

·        Today’s Exam Data options are changed

·        Lab Screening tests have been moved from page two to the front page=

·        Added option to Hemoglobin and Urine pregnancy testing results=

·        Provider Types are changed

·        Birth control methods are repositioned, deleted, or changed

·        Coding hints are included

·        Pap Tests for Screening are added to front page

·        General procedures and sterilization procedures are regrouped<= /o:p>

·        New sterilization procedure Essure added

·        Mammogram Screening Referral codes repositioned and expanded

·        Drugs/Supplies/Devices section revised

·        Tracking dispensed Emergency Contraception added<= /p>

·        Tracking whether prescriptions are written regrouped

·        Add secondary diagnosis, matching labs, and medications are grouped together on second page

 

The following tables list data elements by closing page columns:

&n= bsp;

NEW SOFP ENCOUNTER CLOSING PAGE 1 – COLUMN 1

 

R/O

FIELD NAME<= /o:p>

O

OFFI= CE VISITS

 

NEW CLIENT E &am= p; M

99201  10 min M/F

99202  20 min M/F

99203  30 min M/F

99204  45 min M/F

ESTABLISHED CLIE= NT E & M

99211  5 min M/F=

99212  10 min M/F

99213  15 min M/F

99214  25 min M/F

O

EDUC= ATION & COUNSELING

 

Z9750 Group M/F

Z9751 Individual 10 min M/F

Z9752 15 min M/F

Z9753 16-30 min M/F

Z9754 31-45 min M/F

T= oday’s Exams have been

C= hanged.

<= o:p> 

B= e sure to indicate appropriate exam completed,

especially if No Physical Exam was performed
 
O

TODA= Y'S EXAMS

 

Clinical Breast Exam (CBE)

CBE Referred

Pelvic Exam

No Physical Exam

Testicular Exam

Prostate Exam

O

LABS: SCREENING TESTS (All S-Codes except S60)

 

86592 VDRL, RPR

86701 HIV-I

86702 HIV-II

86703 HIV-I & HIV-II single assay

87081 GC culture

87491 Chlamydia NAAT

87591 GC NAAT

87800 Inf agent antigen detection (direct probe)=

O

Refl= ex tests based on POS screening tests

 

86781 TP-Confirmatory test

86593 Syphilis test, Quantitative

86689 HIV confirmation

87490 Chlamydia direct probe

87590 GC direct probe

O

BLOO= D DRAW & OTHER IN-HOUSE LABS

 

99000 Blood Draw

P= rovider Options have been changed.

<= o:p> 

B= e sure to select appropriate provider of services.
 
R

PROV= IDER TYPE (SELECT ONE)

 

Physician

Nurse Practitioner

Physician Assistant

Certified Nurse Midwife

RN/LPN

Counselor/CHE/MA/Technician

 

NEW S= OFP ENCOUNTER CLOSING PAGE 1 – COLUMN 2

 

R

17a. FEMALE PRIMARY METHOD

F= emale “Primary Method” section has changed.

<= o:p> 

I= tem #4. 1-month Hormonal Injection has been removed.

<= o:p> 

N= ote: Item numbering is left “as is” purposely.

 

F= emale “No Method” section options changed.
 
 

1. Female Sterilization

2. Intrauterine Device (IUD)

3. Hormonal Implant

5. 3-Month Hormonal Injection

6. Oral Contraceptive

7. Contraceptive Patch

8. Vaginal Ring

9. Cervical Cap/Diaphragm

10. Contraceptive Sponge

11. Female Condom

12. Spermicide (Used Alone)

13. Fertility Awareness Method

14. Abstinence

15. Other Method (Withdrawal)

R

17b. FEMALE NO METHOD

F= emale “Rely on Male Method” section now includes No Data Collected.

<= o:p> 

B= e sure to mark this option if clinician has not marked a BCM.
 
 

17. Pregnant

18. Seeking Pregnancy

19. Infertile/Same Sex Partner

R

17c. FEMALE RELY ON MALE METHOD

 

20. Vasectomy

21. Male Condom

 

No Data Collected

R

17d.= MALE PRIMARY METHOD

M= ale BCM section has been divided.

<= o:p> 

Note changes to options in s= ection 17e.
 
 

1. Vasectomy

2. Male Condom

3. Fertility Awareness

4. Abstinence

5. Other Method (Withdrawal)

R

17e.= MALE NO METHOD

Male “= No Method” section now includes No Data Collected.

 <= /o:p>

Be sure to m= ark this option if clinician has not marked a BCM.

 
 
 

7. Partner Pregnant

8. Partner Seeking Pregnancy

9. Infertile/Same Sex Partner

10. Rely on Female Method(s)

 

No Data Collected

 

EXAM= ROOM

 

Z7500

 

Z7506

 

SECO= NDARY DIAGNOSIS

 

 

 

 

NEW SOFP ENCOUNTER CLOSING PAGE 1 – COLUMN 2

 

R/O

FIELD NAME<= /o:p>

 

Prim= ary Diagnosis (Non-SOFP Visit Type)

 

 

 

PRIM= ARY DIAGNOSIS (S-Codes required for each claim)

 

ORAL/PATCH/VAGIN= AL RING

 

S10.1 (V25.0) Evaluate/Initiate

 

S10.2 (V25.40) Maintain

 

INJECTION

 

S20.1 (V25.02) Evaluate/Initiate

 

S20.2 (V25.40) Maintain

 

IMPLANT

 

S30.1 (V25.43) Evaluate/Initiate

 

S30.2 (V25.4) Maintain

 

IUD/IUC

 

S40.1 (V25.1) Evaluate/Initiate

 

S40.2 (V25.40) Maintain

 

BARRIERS and SPERMICIDE

 

S50.1 (V25.02) Evaluate/Initiate

 

S50.2 (V25.40) Maintain

 

PREGNANCY TESTIN= G

 

S60.1 (V72.4) Pregnancy Test ONLY

 

S60.2 (V22.0) Pregnancy Confirmation

 

VASECTOMY

 

S80.1 (V25.0) VAS Evaluation

 

S80.2 (V25.2) VAS Surgery

O

LABS= : SPECIFIC TO S-CODE DIAGNOSIS

 

80061 Lipid Profile

 

80076 LFT

 

81000 UA Dipstick w/ Micro

 

81001 UA Auto w/ Micro

 

81002 UA Dipstick w/o Micro

 

81003 UA Auto w/o Micro

 

81025 Urine Pregnancy Test

 

82465 Cholesterol

 

82947 Glucose

 

82951 2-Hr GTT

 

85013 Hematocrit, Spun

 

85014 Hematocrit

 

85018 Hemoglobin

 

85025 CBC w Differential

 

85027 CBC w/o Differential

&nbs= p;

 

&nbs= p;

 

NEW S= OFP ENCOUNTER CLOSING PAGE 1 –

COLUM= N 2

&nbs= p;

 

R

CYTO= LOGY ORDERS FOR LABS

P= ap test codes 88142 – 88164 are shown on the closing page.

<= o:p> 

A= dditional codes 88165-88175 may be used as well.
 
 

PAP TEST CODES

 

88142 Pap Test Code

 

88143 Pap Test Code

 

88147 Pap Test Code

 

88148 Pap Test Code

 

88164 Pap Test Code

 

88165 Pap Test Code

 

88167 Pap Test Code

 

88174 Pap Test Code

 

88175 Pap Test Code

 

MISC= ELLANEOUS CODES

 

 

New sterilizat= ion device added.
 

 

NEW SOFP ENCOUNTER CLOSING PAGE 1 – COLUMN 3

 

R/O

FIELD NAME<= /o:p>

R 

PROC= EDURES

 

11975 Implant Insertion

 

11976 Implant Removal

 

11977 Implant Removal/Insertion

 

57170 Diaphragm/Cervical Cap, Fitting

 

58300 IUD/IUC Insertion

 

58301 IUD/IUC Removal

S= pecific sterilization procedures are now added to the closing page.

<= o:p> 

N= ew sterilization procedure 58565 Essure added
 
R 

STER= ILIZATION PROCEDURES

 

58600 Mini Lap TL

 

58615 Mini Lap TL with Clip

 

58670 Lapscope Fulguration

 

58671 Lapscope with Ring or Clip

 

55250 Vasectomy

 

58565 Essure Procedure

 

Addi= tional Related Sterilization Procedures

 

 

 R

MAMM= OGRAM  SCREENING REFERRAL

 

77057

 

G0202

 

77052

R 

DRUG= S/CONTRACEPTIVE/DEVICES

 

Essure Device Bilateral

 

Essure Device Unilateral

 

Contraceptive Implant

 

Condoms

 

Suppositories

 

Foam

 

Jelly

 

Cream

 

Vaginal Film (VCF)/Gel

 

Contraceptive Sponge

 

Lubricant

 

Fertility Awareness Supplies

 

Diaphragm

 

Cervical Cap

 

Oral Contraceptives

 

Contraceptive Injection

 

Patch

 

Ring

If Emergency Contraception is ordered, be sure to report when it is dispensed.
 
 

Emergency Contraception

 R

Emergency Contraception Dispensed?

 

IUD/IUC/IUS

 

Other

 

TABL= E B (See Dx 626.6)

 

Estradiol (Breakthrough Bleeding)

 

MISC= ELLANEOUS MEDICATIONS

 

 

 

NEW SOFP ENCOUNTER CLOSING PAGE 2 – COLUMN 1

 

Chlamydia 

 

 

099.41

Ct, urethritis

 

099.52

Ct, anus, rectum

 

099.53

Ct, lower GU, cervix

 

099.40 (M)

NGU/NSU

 

 

604.90 (M)

Acute epididymitis/orchitis

616.0 (F)

Cervicitis

 

 

V01.6 (M/F) &nb= sp;

Ct exposed partner

 

Labs   (For Screening Tests, see S-Codes)

87205  G= ram Stain (Males only)

 

Drugs

 

 

 

23B  Azithromycin 250mg tabs

 

23D  Azithromycin 1gm pkt

 

23C  Azithromycin 500mg tabs

 

34D  Doxycycline  100mg ta= bs

 

For alternative regimens, see Grid<= /i>

 

 

 

 

 

Gonorrhea   

 

 

098.0

Urethritis

 

 

098.12

Prostatitis

 

 

098.15

Gonococcal cervicitis (acute)

098.6

GC, pharynx

 

098.7

GC, anus/rectum

 

099.40 (M)

NGU/NSU

 

 

616.0 (F)

Cervicitis

 

 

V01.6 (M,F)

GC exposed partner

 

Labs  (For Screening Tests, see S-Codes)

87205  G= ram Stain (Males only)

 

Drugs

 

 

 

54A  Cef= ixime 400mg tab

 

27A  Ceftriaxone 250 mg IM

 

For alternative regimens, see Grid<= /i>

 

 

 

 

 

Herpes, Genital 

 

 

054.11

HSV vulvovaginitis

 

054.12

Herpes vulva

 

054.13

Herpes penis

 

608.89 (M) 

Penile ulcer

 

616.50 (F) &nbs= p;

Vulvar ulcer

 

Labs  Limited to ICD-9s 608.89 and 616.50

87252  H= SV culture

 

 

87255  H= SV culture

 

 

87273  H= SV DFA, type 2

 

 

Drugs

 

 

 

21A  Acy= clovir 200mg

 

 

21D  Acy= clovir 400mg

 

 

21C  Acy= clovir 800mg

 

 

 

NEW SOFP ENCOUNTER CLOSING PAGE 2 – COLUMN 1

 

PID (Females) 

 

 

614.0

PID

614.2

PID, NOS

615.0

Acute myometritis

Labs 

 

 

 

85025 CBC/diff

 

 

85651 ESR (sed rate), non-auto

85652 ESR (sed rate), auto

 

Drugs

 

 

 

26A  Cef= oxitin 1gm IM

 

26B  Cef= oxitin 2gm IM

 

27A  Ceftriaxone 250mg IM

 

34D  Dox= ycycline 100mg tabs

47A  Probenecid 500m= g tabs

 

For alternative regimens, see Grid 

 

 

 

 

Syphilis  

 

 

 

091.0  <= o:p>

Primary

 

 

091.3

Secondary

 

092.9

Early latent

 

096

Late latent

 

097.1

Latent, unspecified

616.50 (F) 

Vulvar ulcer

608.89 (M) 

Penile ulcer

 

V01.6 (M/F) 

Syphilis exposed partner

Labs  (For Screening Tests, see S-Codes)

Limited to ICD-9s 091.0, 091.3, 092.9, 096, 097.1

86593  Syphilis, quantitative

 

Drugs

 

 

 

44C  Benzathine PCN 1.2m units/cc

44D  Benzathine PCN 2.4m units/cc

For alternative regimens, see Grid<= /i>

 

NEW SOFP ENCOUNTER CLOSING PAGE 2 – COLUMN 2

 

Trichomoniasis =  

 

 

 

 

131.01

Trichomonal vulvovaginitis

131.02

Trichomonal urethritis (M/F)

099.40

NGU/NSU (M)

V01.6

Trichomoniasis exposed partner (M/F)

Labs 

 

 

 

 

83986

pH (Females only)

 

 

Q0111

Wet mount (Provider performed)

87210

Wet mount  (Sent to lab)

 

Drugs

 

 

 

 

40E  Metronidazole 500mg tabs

 

For alternative regimens, see Grid<= /i>

 

Vulvovaginitis

 

 

 

112.1

Candidal vulvovaginitis

616.10

Vaginitis/vulvitis/BV

Labs 

 

 

 

 

83986

pH (females only)

 

 

Q0111

Wet mount (Provider performed)

87210

Wet mount (Sent to lab)

 

Drugs

 

 

 

 

Vag= inal candidiasis:

 

 

24A  Butoconazole 2%SR cream

 

32B  Clotrimazole 1%crm

 

 

32D  Clotrimazole 2%crm

 

 

32A  Clotrimazole 100mg vag tabs

 

32E  Clotrimazole 200mg vag tabs

 

38A  Fluconazole 150mg tab

 

 

41D  Miconazole 2%crm

 

 

41E  Miconazole 4%crm

 

 

41B  Miconazole 100mg vag supp

 

41C  Miconazole 200mg vag supp

 

49A  Terconazole  0.4%crm<= o:p>

 

 

49B  Terconazole  0.8%crm<= o:p>

 

 

49C  Terconazole  80mg sup= p

 

Bac= terial vaginosis:

 

 

40D  Metronidazole 250mg tabs

 

40E  Metronidazole 500mg tabs

 

40A  Metronidazole 0.75% vag gel

 

31A  Clindamycin 2% crm

 

 

For alternative regimens, see Grid<= /i>

 

 

NEW SOFP ENCOUNTER CLOSING PAGE 2 – COLUMN 2

 

Warts, Genital Only

 

 

 

 

078.0     

Molluscum

078.10   <= /span>

Viral warts

 

078.11   <= /span>

Condylomata

 

Procedures

 

 

 

 

 

54050  <= o:p>

Chem destr, penile lesion

 

 

 

54056

Cryo destr, penile lesion

 

 

 

54100  <= o:p>

Biopsy, penis

 

 

 

 

56501

Destruction vulvar lesion

 

 

 

57061

Destruction vaginal lesion

 

 

 

56605

Biopsy, vulva

 

 

 

 

Labs 

 

 

 

 

 

 

88305

Surgical pathology

 

 

 

Drugs

 

 

 

 

 

 

51A  Imi= quimod 5% cream

 

 

 

45A  Pod= ofilox 0.5% solution/gel

 

 

 

Urinary Tract Infections (Females Only)

 

 

595.0

Acute cystitis

599.71

Gross hematuria

788.1

Dysuria

788.41

Urinary frequency

789.09

Abdominal pain,bilateral

Labs 

For symptomatic females only

 

 

81000

Urinalysis, dipstick w/micro

 

 

 

81001

Urinalysis, automated w/micro

 

 

81002

Urinalysis dipstick w/o micro

 

 

 

81003

Urinalysis, automated w/o micro

 

 

81005

Urinalysis, qualitative

 

 

 

81015

Urine microscopy

 

 

 

87086

Urine culture

 

 

 

 

87181

Susceptibility studies; agar (reflex only)=

 

87184

Susceptibility studies; disk (reflex only)=

 

87186

Susceptibility studies, microdilution, or agar (refle= x)

Drugs

 

 

 

 

 

 

28A Cephalexin 250mg tabs

 

 

 

28B Cephalexin 500mg tabs

 

 

 

29D Ciprofloxacin 250mg tabs

 

 

 

29B Ciprofloxacin 500mg tabs

 

 

 

29E Ciprofloxacin 500mg SR tabs

 

 

 

42A Nitrofurantoin 100mg

 

 

 

 

42C Nitrofurantoin 100mg SR tabs

 

 

 

48B  TMP= /SMX 80/400mg tabs

 

 

 

48A  TMP= /SMX 160/800mg tabs

 

 

 

 

NEW SOFP ENCOUNTER CLOSING PAGE 2 – COLUMN 3

 

Cervical Abnormalities (Females aged 15-55)

 

 

795.01

ASC-US Pap

 

 

 

 

 

795.02

ASC-H Pap

 

 

 

 

 

795.03

LGSIL Pap

 

 

 

 

 

795.04

HGSIL Pap

 

 

 

 

 

795.05

Abn Pap w/HPV high risk positive

 

 

 

795.08

Unsatisfactory Cervical Cytology smear

 

 

622.2

Leukoplakia, cervix

 

 

 

 

Procedures

 

 

 

 

 

 

 

57452

Colposcopy

 

 

 

 

 

57454

Colpo w/biopsy & ECC

 

 

 

 

57455

Colpo w/biopsy

 

 

 

 

 

57456

Colpo w/ECC

 

 

 

 

 

Labs  Not= e: 87621 not reimbursed with ICD-9s 795.04, 622.2

 

87621

DNA amplified probe HPV high risk; ages>21

 

 

88305

Surgical pathology

 

 

 

 

 

88141

Pap requiring phys. Interpretation<= /p>

 

 

 

795.00   <= /span>

AGC Pap