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ub04_form.php
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ub04_form.php
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<?php
/**
* UB04 Claims Form
*
* @package OpenEMR
* @link https://www.open-emr.org
* @author Jerry Padgett <[email protected]>
* @author Brady Miller <[email protected]>
* @copyright Copyright (c) 2017 Jerry Padgett <[email protected]>
* @copyright Copyright (c) 2019 Brady Miller <[email protected]>
* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
*/
/* $isAuthorized tells us if the form is for user UI or claim processing and provides another security check */
if ($isAuthorized !== true) {
require_once("./ub04_dispose.php");
$isAuthorized = 0;
$pid = $_REQUEST['pid'] ? $_REQUEST['pid'] : '0';
$encounter = $_REQUEST['enc'] ? $_REQUEST['enc'] : '0';
$action = $_REQUEST['action'] ? $_REQUEST['action'] : false;
$payerid = $_REQUEST['id'] ? $_REQUEST['id'] : '0';
$imgurl = $GLOBALS['images_static_relative'];
if ($action == 'payer_defaults') {
$ub04id = get_payer_defaults($payerid);
} elseif ($pid && $encounter) {
$ub04id = json_encode(get_ub04_array($pid, $encounter));
} else {
exit(xlt("Sorry! Not Authorized."));
}
} else {
$imgurl = "../../../../public/images";
}
use OpenEMR\Core\Header;
?>
<!DOCTYPE html >
<html>
<head>
<meta http-equiv="X-UA-Compatible" content="IE=Edge" />
<meta charset="utf-8" />
<?php if ($isAuthorized !== true) {
Header::setupHeader(['no_main-theme', 'opener', 'common', 'datetime-picker', 'select2']);
?>
<script>
$(function () {
$( "[title*='DATE']" ).datetimepicker({
<?php $datetimepicker_timepicker = false; ?>
<?php $datetimepicker_showseconds = false; ?>
<?php $datetimepicker_formatInput = false; ?>
<?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
<?php echo(",validateOnBlur: false, formatDate: 'mdy', format: 'mdy'") ?>
});
$(".user").on( 'dblclick', function( event ) {
event.preventDefault();
selectUser(this.id,event);
});
$("#dismissHelp").click(function(e){
e.preventDefault();
$('#formHelp').toggle();
});
$(function () {
$("[title*='REVENUE CODE']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "revenue_code",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$(function () {
$("[title*='OCCURRENCE CODE']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "occurrence_code",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$(function () {
$("[title*='OCCURRENCE SPAN CODE']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "occurrence_span_code",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$(function () {
$("[title*='VALUE CODE']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "value_codes",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$(function () {
$("[title*='CONDITION CODE']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "condition_code",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$(function () {
$("[title*='STATUS']").select2({
ajax: {
url: "./ub04_helpers.php",
dataType: 'json',
data: function(params) {
return {
code_group: "patient_status_code",
term: params.term
};
},
processResults: function(data) {
return {
results: $.map(data, function(item, index) {
return {
text: item,
id: index,
}
})
};
return x;
},
cache: true
}
});
});
$('form :input').change(function(e){
formChanged = true;
$(this).css("color","red");
return false;
});
});
</script>
<?php } else {?>
<?php } ?>
<script>
var pid;
var encounter;
var align = true;
var isTemplate;
var ub04id = Array();
payerid = <?php echo js_escape($payerid);?>;
pid = <?php echo js_escape($pid);?>;
encounter = <?php echo js_escape($encounter);?>;
isTemplate = <?php echo js_escape(($isAuthorized === true ? $isAuthorized : 0)); ?>;
ub04id = <?php echo $ub04id;?>;
function adjustForm()
{
// cycle trough the input fields
// rem form index i is not same as formid index ii
var inputs = Array.prototype.slice.call(document.forms[0]);
Array.prototype.forEach.call(inputs, function(el, i) {
var type = el.getAttribute('type');
var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
var title = el.getAttribute('title');
var max = el.getAttribute('maxlength');
var w = el.clientWidth;
var size = w;
if( ta === 'right' ){
if(title.indexOf("CHARGES") !== -1){
w = size - 14;
if(!isTemplate){ w = size - 8; }
}
else{
w = size - 8;
if(!isTemplate){ w = size - 4; }
}
el.style.width = w + 'px'
}
el.style.top = (el.offsetTop+3)+'px';
if( ta === 'left' )
el.style.left = (el.offsetLeft+2)+'px';
var ii = i+1;
if(typeof(ub04id[ii]) != 'undefined' && ub04id[ii] !== ""){
var val = ub04id[ii];
if( val.length > max && max > 0 ){
val = ub04id[ii].substring(0,max);
}
document.getElementById("ub04id"+ ii.toString()).value = val;
}
});
return false;
}
<?php if ($isAuthorized !== true) {?>
var formChanged = false;
function rewrite(ub04id){
var inputs = Array.prototype.slice.call(document.forms[0]);
Array.prototype.forEach.call(inputs, function(el, i) {
var max = el.getAttribute('maxlength');
var ii = i+1;
if(typeof(ub04id[ii]) != 'undefined'){
var val = ub04id[ii];
if( val.length > max && max > 0 ){
val = ub04id[ii].substring(0,max);
}
document.getElementById("ub04id"+ ii.toString()).value = val;
}
});
}
function cleanUp()
{
if(payerid === '0'){
window.opener.SubmitTheScreen();
}
window.close()
}
function selectUser(formid,event) {
var title = 'Providers';
var params = {
buttons: [
{text: 'Cancel', close: true, style: 'secondary btn-sm'}
],
type: 'GET',
title: title,
size: 'modal-mlg',
url: './ub04_helpers.php?action=user_select&formid=' + encodeURIComponent(formid)
};
return dialog.ajax(params).then(function () {
});
}
function updateProvider(formid, selected)
{
document.getElementById(formid).value = selected.npi;
if(formid === 'ub04id379'){
document.getElementById('ub04id388').value = selected.lname;
document.getElementById('ub04id389').value = selected.fname;
document.getElementById('ub04id289').value = selected.taxonomy;
}
else if(formid === 'ub04id390'){
document.getElementById('ub04id400').value = selected.lname;
document.getElementById('ub04id401').value = selected.fname;
document.getElementById('ub04id296').value = selected.taxonomy;
}
else if(formid === 'ub04id406'){
document.getElementById('ub04id413').value = selected.lname;
document.getElementById('ub04id414').value = selected.fname;
document.getElementById('ub04id303').value = selected.taxonomy;
}
else if(formid === 'ub04id420'){
document.getElementById('ub04id427').value = selected.lname;
document.getElementById('ub04id428').value = selected.fname;
}
return false;
}
function disposeSave(action)
{
var htmlout = "";
var inputs;
var slice = Array.prototype.slice;
inputs = slice.call(document.forms[0]);
Array.prototype.forEach.call(inputs, function(el, i) {
var ii = i+1;
var tmp = document.getElementById("ub04id"+ ii.toString()).value;
if(tmp){
ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
}
});
ub04idSave = JSON.stringify(ub04id);
var qstr = param({ handler: 'edit_save',pid:pid,encounter:encounter,action:action,ub04id:ub04idSave });
location.href='ub04_dispose.php?'+qstr;
}
function postClaim(action)
{
var inputs;
var c = [];
var slice = Array.prototype.slice;
inputs = slice.call(document.forms[0]);
Array.prototype.forEach.call(inputs, function(el, i) {
var ii = i+1;
var tmp = document.getElementById("ub04id"+ ii.toString()).value;
if(tmp){
var row = el.offsetTop.toString();
var col = el.offsetLeft.toString();
var max = el.getAttribute('maxlength');
var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
var w = window.getComputedStyle(el,null).getPropertyValue("width");
var ob = {fld:ii,top:row,left:col,max:max,align:ta,width:w};
c.push(ob);
ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
}
});
var cj = JSON.stringify(c);
ub04idSave = JSON.stringify(ub04id);
var xhr = new XMLHttpRequest();
xhr.open('POST', 'ub04_dispose.php');
xhr.setRequestHeader("Content-Type", "application/x-www-form-urlencoded");
xhr.onload = function() {
if (xhr.status === 200) {
console.log(this.responseText ? this.responseText : 'no response');
if(this.responseText === 'done')
alert(<?php echo xlj("Save Completed")?>);
}
};
if(action === 'payer_save'){
var qs = param({handler:action,payerid:payerid,ub04id: ub04idSave})
}
else if(action === 'batch_save'){
var qs = param({handler:action,pid:pid,encounter:encounter,ub04id:ub04idSave,loc:cj})
}
xhr.send(qs);
}
function param(object)
{
var encodedString = '';
for (var prop in object) {
if (object.hasOwnProperty(prop)) {
if (encodedString.length > 0) {
encodedString += '&';
}
encodedString += encodeURI(prop + '=' + object[prop]);
}
}
return encodedString;
}
var scale = 1.25;
function myZoom()
{
var el = document.getElementById('p1');
scale += 0.05;
if(scale > 1.25) scale = 1.0;
el.style.transform = 'scale(' + scale + ')';
}
function resetClaim(){
var msg = <?php echo xlj('This action will reset your claim!'); ?> + '\n' + <?php echo xlj('Click OK if you are sure.'); ?>;
var yn = confirm(msg);
if (yn !== true) {
return false;
}
$.ajax({
type: 'GET',
url: 'ub04_dispose.php',
data: {handler:'reset_claim',pid:pid,encounter:encounter},
dataType: 'json',
success: function( rtn ) {
ub04id = rtn;
document.getElementById('ub04Data').reset();
rewrite(ub04id);
}
});
}
<?php } ?>
</script>
<style>
.container {
text-align:center;
}
.ui-autocomplete {max-height: 250px; max-width: 25%; width: 50%; overflow-y: auto; overflow-x: hidden;}
input{
z-index:2;
text-transform: uppercase;
position: absolute; border-width:0px;
height:14px; color: rgb(0,0,0);
background: transparent; border-color:transparent;
font:normal 10pt 'Times New Roman', Times, serif;
}
textarea{
z-index:2;
text-transform: uppercase;
position: absolute; border-width:0px;
color: rgb(0,0,0);
background: transparent; border-color:transparent;
font:normal 10pt 'Times New Roman', Times, serif;
}
input:focus{color: blue !important;}
body {
padding: 0px;
margin-top: 35px;
margin-bottom: 35px;
background-color: lightgrey;
}
#p1 {
transform: scale(1.2);
transform-origin: top center;
margin-top: 0px;
margin-left: auto;
margin-right: auto;
}
#menu {
text-align: center;
z-index: 9999;
background-color: ghostwhite;
position: fixed;
padding:5px 5px 5px 5px;
margin-left: auto;
margin-right: auto;
/* opacity: 0.8; */
top: 0px;
}
@media print {
.datepicker{
border-color:transparent !important;
background-color:transparent !important;
}
.user{
background-color:transparent !important;
border-color:transparent !important;
}
body {
padding: 0px;
margin: 0px;
background-color: #fff;
}
.formhide {
display: none;
}
#p1 {
margin-top: 0px;
margin-left: 0px;
margin-right: 0px;
}
input{
z-index:2;
text-transform: uppercase;
position: absolute; border-width:0px;
height:14px; color: rgb(0,0,0);
background: transparent; border-color:transparent;
font:normal 10pt 'Times New Roman', Times, serif;
}
textarea{
z-index:2;
text-transform: uppercase;
position: absolute; border-width:0px;
color: rgb(0,0,0);
background: transparent; border-color:transparent;
font:normal 10pt 'Times New Roman', Times, serif;
}
}
#ub04id1{ left:301px; top:19px; width:264px; text-align:left;}
#ub04id2{ left:26px; top:19px; width:264px; text-align:left;}
#ub04id3{ left:599px; top:19px; width:263px; text-align:left;}
#ub04id4{ left:26px; top:37px; width:264px; text-align:left;}
#ub04id5{ left:301px; top:37px; width:264px; text-align:left;}
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</style>
</head>
<body onload="adjustForm();">
<div class="container" id="formContainer">
<?php if ($isAuthorized !== true) {?>
<h3 class='formhide'><em><?php echo xlt('Claim Edit') ?> </em><button class="btn btn-sm btn-warning" onclick="myZoom()" ><?php echo xlt('Zoom'); ?></button></h3>
<div class="navbar-fixed-top formhide" id='menu'>
<?php if ($pid && $encounter) {?>
<button class="btn btn-sm btn-success" onclick="disposeSave('form')" title=<?php echo xla("Save for printing with form") ?>><?php echo xlt('Pdf With Form'); ?></button>
<button class="btn btn-sm btn-success" onclick="disposeSave('noform')" title=<?php echo xla("Save for printing to a pre printed sheet"); ?>><?php echo xlt('Pdf Without Form'); ?></button>
<button class="btn btn-sm btn-success" onclick="postClaim('batch_save')" title=<?php echo xla("Save claim for batch processing"); ?>><?php echo xlt('Save Claim'); ?></button>
<?php } else {?>
<button class="btn btn-sm btn-success" onclick="postClaim('payer_save')"><?php echo xlt('Save Payer'); ?></button>
<?php } ?>
<button class="btn btn-sm btn-danger" onclick="resetClaim()" title=<?php echo xla("Reset claim form to Fee Sheet Version"); ?>><?php echo xlt('Reset Version'); ?></button>
<button class="btn btn-info btn-sm" type="button" onclick="window.scrollTo(0, 0);$('#formhelp').toggle()"><?php echo xlt('Help'); ?></button>
<button class="btn btn-sm btn-danger" onclick="cleanUp()"><?php echo xlt('Return'); ?></button>
</div>
<div id='formhelp' class='jumbotron jumbotron-fluid' style='display:none; text-align:center; width: auto; margin: 5px auto;'>
<h4>Help</h4>
<div style='text-align:left;'>
* <?php echo xlt('Many code items have a lookup/hint.'); ?>
<?php echo xlt('Either type a search term in appropriate box or double click box to see available codes.'); ?><br />
* <?php echo xlt('Double Clicking a NPI box will bring up a current Users dialog for providers.'); ?><br />
* <?php echo xlt('PDF buttons will save, mark claim reviewed and download claim'); ?><br />
* <?php echo xlt('Reset button resets the edited claim to the fee sheet version. If subsequently saved, it will replace last claim version and be considered reviewed. Otherwise, claim is reset to fee sheet version.'); ?><br />
* <?php echo xlt('Save button saves claim and marks reviewed'); ?><br />
* <?php echo xlt('Return button simply returns, then refreshes billing manager'); ?><br /><br />
</div>