Encounter completion — charges & finalize

Code the visit (E/M & CPT)

The Charges section captures the billing codes. Pick an Evaluation & Management level with one click and Hero EMR fills in the matching CPT; add any procedure or other CPT codes by search.

1. Choose the E/M level. The buttons Straightforward, Low, Moderate, High, New Low, and New Moderate map to the right code — e.g. Moderate → 99214 — Established patient office visit, moderate complexity (30–39 min). Picking a level turns the E/M tracker chip green.
2. Add other CPT codes. Use Search CPT codes for procedures, vaccines, or anything beyond the office visit. Manage curates your charge favorites, and is also where you rename or hide the No charge button.
3. Or close the visit without an E/M code. Two pinned buttons sit at the front of the quick-button grid:
   • No charge — close the visit with no billing at all. Nothing is charged, no insurance claim is created, and the visit reports as “No billing” in the Billing Command Center. It is shown by default; you can rename it or hide it from your own charge favorites under Manage.
   • Cash pay — create a patient balance instead of an insurance claim. The caption under the button shows the configured price for this patient and visit type. If none is configured it reads Price required, and an administrator or billing staff member with charge-management access must enter a one-time amount before you can sign. Where a price is configured, the same permission lets you override it for this visit only.
   Either choice satisfies the “E/M or procedure code” requirement at signing, so you can close the visit without coding it.

Patient instructions

Hero EMR drafts after-visit patient instructions from your note. Review them, edit, or write your own, then they travel with the visit summary the patient receives.

1. Review the draft. The Instructions section proposes plain-language instructions based on the note’s plan.
2. Edit or add your own. Use Edit to revise, + Add instructions manually to write from scratch, or Copy to clipboard to reuse elsewhere.

Schedule the follow-up

The Follow-up section is pre-set from your note’s plan and lets you confirm the timing and book the next visit without leaving the encounter.

1. Check what’s already booked. Your Upcoming Appointments at the top of the section lists this patient’s scheduled visits (date, time, visit type) so you don’t double-book a follow-up that already exists.
2. Confirm the timing. Pick 2 weeks, 1 month, 3 months, 6 months, or Custom. Hero EMR shows a Recommended follow-up date based on your choice.
3. Set the visit type and book. Choose the Visit Type. Duration beside it is a read-only readout — it comes from that visit type’s default duration, so change the duration by changing the visit type (or its definition under Visit types). The star inside each visit-type option saves it as your default follow-up type (tooltip: Set as default follow up type).
   • Schedule Now does not create the appointment on the spot. It opens the scheduling workspace in a new tab, prefilled with the recommended date, the chosen visit type, and next-available search, where you pick the actual slot.
   • Or leave it as a follow-up request to be booked later. The F/U tracker chip turns green once set.
4. Once a visit is on the calendar. The request UI is replaced by a Follow-up appointment scheduled panel showing the date, time, and visit type, with Reschedule and Cancel appointment buttons. As it says there, the automatic follow-up request is turned off while that appointment is on the calendar — the two are mutually exclusive.

Reconcile medications

The Med Management section is where you reconcile the patient’s list as part of closing the visit. It shows what this encounter adds and lets you discontinue anything no longer needed.

1. Confirm new medications. New Medications From This Encounter lists what you prescribed today (read-only here — edit it back under Writing a prescription).
2. Discontinue what’s ending. Under Active Medications, check any medication to discontinue it when the encounter is finalized. Each row shows strength, route, and sig so you can decide at a glance. Checking a row opens a Discontinuation reason box — fill it in so the stop is documented. A running N to discontinue badge sits next to the section heading.
3. Look for the Suggested badge. A medication Hero EMR proposed stopping from your note is tagged Suggested. It is still just a proposal — nothing is discontinued unless you check the box yourself.

Build favorites to move faster

Favorites turn the codes and orders you use most into one-click chips. They’re personal to you and appear at the top of the matching section.

Sign and close the visit

Sign & Close Visit finalizes the visit at once. It is the single action that turns your worksheet into a signed, billed, transmitted encounter. The footer chips are a progress hint, not the gate — the real requirements are checked when you click, and anything missing is reported inline and scrolled to instead of signing.

1. Meet the requirements that actually block signing.
   • At least one diagnosis. “Encounter requires at least one diagnosis before completion.”
   • Charges. An E/M code or at least one procedure code — unless you chose No charge or Cash pay, either of which satisfies this on its own (see Charges & E/M).
   • Every order linked to a diagnosis. If any medication, lab, imaging, referral, or screener has no diagnosis association, signing stops and the Associations grid is highlighted.
   • A pharmacy, if any prescription is still unsent. “Select a preferred pharmacy before signing since you have unsent prescriptions.”
   The Orders and F/U chips are progress hints only — a visit with no orders and no follow-up signs perfectly well.
2. Sign controlled prescriptions first. Any controlled order must be signed via EPCS before it can be transmitted, and an unsigned one keeps Sign & Close Visit disabled until you go back to Orders and sign it.
3. Answer the billability advisory if it appears. On a visit that will be billed to insurance, Hero EMR checks your diagnosis codes first. If any is a category header or an unrecognized code — a guaranteed clearinghouse rejection — a Some diagnoses can’t be billed as-is dialog opens with one-click billable subcodes. Pick a subcode, or choose Fix diagnoses to go back to the Diagnoses section. Sign anyway proceeds and records that you acknowledged the codes. This advisory never blocks you, but dismissing the dialog counts as “I’ll fix it” and does not sign.
4. Click Sign & Close Visit. Finalizing signs the note, sends any orders and prescriptions you haven’t already sent individually, submits the charges to billing, applies any medication discontinuations, and creates the follow-up request — in one step. Ctrl/Cmd+Enter does the same thing from the keyboard.