interface/forms/misc_billing_options/new.php

   1 <?php
   2 /*
   3  * new.php for the creation of the misc_billing_form
   4  *
   5  * This program creates the misc_billing_form
   6  *
   7  * Copyright (C) 2007 Bo Huynh
   8  * Copyright (C) 2016 Terry Hill <terry@lillysystems.com>
   9  *
  10  * LICENSE: This program is free software; you can redistribute it and/or
  11  * modify it under the terms of the GNU General Public License
  12  * as published by the Free Software Foundation; either version 3
  13  * of the License, or (at your option) any later version.
  14  * This program is distributed in the hope that it will be useful,
  15  * but WITHOUT ANY WARRANTY; without even the implied warranty of
  16  * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
  17  * GNU General Public License for more details.
  18  * You should have received a copy of the GNU General Public License
  19  * along with this program. If not, see http://opensource.org/licenses/gpl-license.php.
  20  *
  21  * @package OpenEMR
  22  * @author Terry Hill <terry@lilysystems.com>
  23  * @author Brady Miller <brady.g.miller@gmail.com>
  24  * @link http://www.open-emr.org
  25  *
  26  */
  27 $fake_register_globals=false;
  28 $sanitize_all_escapes=true;
  29
  30 require_once("../../globals.php");
  31 require_once("$srcdir/options.inc.php");
  32 require_once("$srcdir/api.inc");
  33 require_once("date_qualifier_options.php");
  34
  35
  36 if (! $encounter) { // comes from globals.php
  37  die(xlt("Internal error: we do not seem to be in an encounter!"));
  38 }
  39
  40 $formid   = 0 + formData('id', 'G');
  41 $obj = $formid ? formFetch("form_misc_billing_options", $formid) : array();
  42
  43 formHeader("Form: misc_billing_options");
  44 function generateDateQualifierSelect($name,$options,$obj)
  45 {
  46     echo     "<select name='".attr($name)."'>";
  47     for($idx=0;$idx<count($options);$idx++)
  48     {
  49         echo "<option value='".attr($options[$idx][1])."'";
  50         if($obj[$name]==$options[$idx][1]) echo " selected";
  51         echo ">".text($options[$idx][0])."</option>";
  52     }
  53     echo     "</select>";
  54
  55 }
  56 function genProviderSelect($selname, $toptext, $default=0, $disabled=false) {
  57   $query = "SELECT id, lname, fname FROM users WHERE " .
  58     "( authorized = 1 OR info LIKE '%provider%' ) AND username != '' " .
  59     "AND active = 1 AND ( info IS NULL OR info NOT LIKE '%Inactive%' ) " .
  60     "ORDER BY lname, fname";
  61   $res = sqlStatement($query);
  62   echo "   <select name='" . attr($selname) . "'";
  63   if ($disabled) echo " disabled";
  64   echo ">\n";
  65   echo "    <option value=''>" . text($toptext) . "\n";
  66   while ($row = sqlFetchArray($res)) {
  67     $provid = $row['id'];
  68     echo "    <option value='" . attr($provid) . "'";
  69     if ($provid == $default) echo " selected";
  70     echo ">" . text($row['lname'] . ", " . $row['fname']) . "\n";
  71   }
  72   echo text($provid);
  73   echo "   </select>\n";
  74 }
  75 ?>
  76 <html>
  77 <head>
  78 <?php html_header_show(); ?>
  79 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-2-1/index.js"></script>
  80 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/textformat.js"></script>
  81 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  82
  83 <!-- pop up calendar -->
  84 <style type="text/css">@import url(<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar.css);</style>
  85 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar.js"></script>
  86 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar_en.js"></script>
  87 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar_setup.js"></script>
  88
  89 </head>
  90 <body class="body_top">
  91 <form method=post <?php echo "name='my_form' " .  "action='$rootdir/forms/misc_billing_options/save.php?id=" . attr($formid) . "'>\n";?>
  92
  93 <span class="title"><?php echo xlt('Misc Billing Options for HCFA-1500'); ?></span><br><br>
  94 <span class=text><?php echo xlt('Checked box = yes ,  empty = no');?><br><br>
  95 <label><span class=text><?php echo xlt('BOX 10 A. Employment related '); ?>: </span><input type=checkbox name="employment_related" value="1" <?php if ($obj['employment_related'] == "1") echo "checked";?>></label><br><br>
  96 <label><span class=text><?php echo xlt('BOX 10 B. Auto Accident '); ?>: </span><input type=checkbox name="auto_accident" value="1" <?php if ($obj['auto_accident'] == "1") echo "checked";?>></label>
  97 <span class=text><?php echo xlt('State'); ?>: </span><input type=entry name="accident_state" size=1 value="<?php echo attr($obj{"accident_state"});?>" ><br><br>
  98 <label><span class=text><?php echo xlt('BOX 10 C. Other Accident '); ?>: </span><input type=checkbox name="other_accident" value="1" <?php if ($obj['other_accident'] == "1") echo "checked";?>></label><br><br>
  99 <span class=text><?php echo xlt('BOX 10 D. EPSDT Referral Code');?> </span><input type=entry style="width: 25px;" size=2 name="medicaid_referral_code" value="<?php echo attr($obj{"medicaid_referral_code"});?>" >&nbsp;&nbsp;&nbsp;&nbsp;
 100 <label><span class=text><?php echo xlt('EPSDT'); ?> : </span><input type=checkbox name="epsdt_flag" value="1" <?php if ($obj['epsdt_flag'] == "1") echo "checked";?>></label><br><br>
 101 <span class="text" title="<?php echo xla("For HCFA 02/12 Onset date specified on the Encounter Form needs a qualifier");?>"></span>
 102 <span class=text title="<?php echo xla('For HCFA 02/12 Box 15 is Other Date with a qualifier to specify what the date indicates');?>"></span>
 103  <tr>
 104   <td><span class=text><?php echo xlt('BOX 14. Is Populated from the Encounter Screen as the Onset Date');?>.</span></td>
 105  </tr><br><br>
 106  <tr>
 107   <td><span class=text><?php echo xlt('BOX 16. Date unable to work from');?>:</span></td>
 108   <td><?php $off_work_from = $obj{"off_work_from"}; ?>
 109     <input type=text style="width: 70px;" size=10 name='off_work_from' id='off_work_from'
 110     value='<?php echo attr($off_work_from); ?>'
 111     title='<?php echo xla('yyyy-mm-dd'); ?>'
 112     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
 113     <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 114     id='img_off_work_from' border='0' alt='[?]' style='cursor:pointer'
 115     title='<?php echo xla("Click here to choose a date"); ?>'></td>
 116  </tr>
 117  &nbsp;&nbsp;
 118 <tr>
 119  <td><span class=text><?php echo xlt('BOX 16. Date unable to work to');?>:</span></td>
 120   <td><?php $off_work_to = $obj{"off_work_to"}; ?>
 121     <input type=text style="width: 70px;" size=10 name='off_work_to' id='off_work_to'
 122     value='<?php echo attr($off_work_to); ?>'
 123     title='<?php echo xla('yyyy-mm-dd'); ?>'
 124     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
 125     <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 126     id='img_off_work_to' border='0' alt='[?]' style='cursor:pointer'
 127     title='<?php echo xla("Click here to choose a date"); ?>'></td>
 128  </tr>
 129     <br><br>
 130
 131     <td class='label'><?php echo xlt('BOX 17. Provider') ?>:</td>
 132     <td><?php  # Build a drop-down list of providers. # Added (TLH)
 133                genProviderSelect('provider_id', '-- '.xl("Please Select").' --',$obj{"provider_id"});
 134                 ?></td>&nbsp;&nbsp;
 135         <td><span class=text><?php  echo xlt('BOX 17. Provider Qualifier'); ?>: </span>
 136         <tr><td><?php
 137                 echo generate_select_list('provider_qualifier_code', 'provider_qualifier_code',$obj{"provider_qualifier_code"}, 'Provider Qualifier Code');
 138             ?></td>
 139         </tr></td>
 140 <br><br>
 141 <tr>
 142  <td><span class=text><?php echo xlt('BOX 18. Hospitalization date from');?>:</span></td>
 143  <td><?php $hospitalization_date_from = $obj{"hospitalization_date_from"}; ?>
 144     <input type=text style="width: 70px;" size=10 name='hospitalization_date_from' id='hospitalization_date_from'
 145     value='<?php echo attr($hospitalization_date_from); ?>'
 146     title='<?php echo xla('yyyy-mm-dd'); ?>'
 147     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
 148     <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 149     id='img_hospitalization_date_from' border='0' alt='[?]' style='cursor:pointer'
 150     title='<?php echo xla("Click here to choose a date"); ?>'></td>
 151  </tr>
 152  &nbsp;&nbsp;
 153  <tr>
 154   <td><span class=text><?php echo xlt('BOX 18. Hospitalization date to');?>:</span></td>
 155   <td><?php $hospitalization_date_to = $obj{"hospitalization_date_to"}; ?>
 156     <input type=text style="width: 70px;" size=10 name='hospitalization_date_to' id='hospitalization_date_to'
 157     value='<?php echo attr($hospitalization_date_to); ?>'
 158     title='<?php echo xla('yyyy-mm-dd'); ?>'
 159     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
 160     <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 161     id='img_hospitalization_date_to' border='0' alt='[?]' style='cursor:pointer'
 162     title='<?php echo xla("Click here to choose a date"); ?>'></td>
 163  </tr>
 164     <br><br>
 165 <span class=text><?php echo xlt('BOX 20. Is Outside Lab used?'); ?>: </span><input type=checkbox name="outside_lab" value="1" <?php if ($obj['outside_lab'] == "1") echo "checked";?>>
 166 <span class=text><?php echo xlt('Amount Charges'); ?>: </span><input type=entry size=7 align='right' name="lab_amount" value="<?php echo attr($obj{"lab_amount"});?>" ><br><br>
 167 <span class=text><?php echo xlt('BOX 22. Medicaid Resubmission Code (ICD-9) ');?></span><input type=entry size=9 name="medicaid_resubmission_code" value="<?php echo attr($obj{"medicaid_resubmission_code"});?>" >
 168 <span class=text><?php echo xlt(' Medicaid Original Reference No. ');?></span><input type=entry size=15 name="medicaid_original_reference" value="<?php echo attr($obj{"medicaid_original_reference"});?>" ><br><br>
 169 <span class=text><?php echo xlt('BOX 23. Prior Authorization No. ');?></span><input type=entry size=15 name="prior_auth_number" value="<?php echo attr($obj{"prior_auth_number"});?>" ><br><br>
 170 <label><span class=text><?php echo xlt('X12 only: Replacement Claim '); ?>: </span><input type=checkbox name="replacement_claim" value="1" <?php if ($obj['replacement_claim'] == "1") echo "checked";?>></label><br><br>
 171 <span class=text><?php echo xlt('X12 only ICN resubmission No.');?> </span><input type=entry size=35 name="icn_resubmission_number" value="<?php echo attr($obj{"icn_resubmission_number"});?>" ><br><br>
 172
 173 <table>
 174 <tr>
 175 <td valign=top>
 176 <span class=text><?php echo xlt('Additional Notes'); ?>: </span><br><textarea cols=40 rows=8 wrap=virtual name="comments" ><?php echo text($obj{"comments"});?></textarea><br>
 177 </td>
 178 </table>
 179 <br>
 180 </tr>
 181
 182  <div>
 183 <!-- Save/Cancel buttons -->
 184 <input type="button" class="save" value="<?php echo xla('Save'); ?>"> &nbsp &nbsp &nbsp &nbsp;
 185 <input type="button" class="dontsave" value="<?php echo xla('Don\'t Save Changes'); ?>"> &nbsp;
 186 </div>
 187 </form>
 188 <script language="javascript">
 189 /* required for popup calendar */
 190 Calendar.setup({inputField:"hospitalization_date_from", ifFormat:"%Y-%m-%d", button:"img_hospitalization_date_from"});
 191 Calendar.setup({inputField:"hospitalization_date_to", ifFormat:"%Y-%m-%d", button:"img_hospitalization_date_to"});
 192 Calendar.setup({inputField:"off_work_from", ifFormat:"%Y-%m-%d", button:"img_off_work_from"});
 193 Calendar.setup({inputField:"off_work_to", ifFormat:"%Y-%m-%d", button:"img_off_work_to"});
 194
 195 // jQuery stuff to make the page a little easier to use
 196
 197 $(document).ready(function(){
 198     $(".save").click(function() { top.restoreSession(); document.my_form.submit(); });
 199     $(".dontsave").click(function() { location.href='<?php echo "$rootdir/patient_file/encounter/encounter_top.php";?>'; });
 200 });
 201 </script>
 202 </body>
 203 </html>