Health Informatics:  Week 4 Critical Reflection Paper Objective: To judgmentally reflect your understanding of the readings and your skill to apply them to your Health care Setting.  ASSIGNMENT GUIDEL

CHAPTER © 2012 The McGraw -Hill Companies, Inc. All rights reserved. McGraw -Hill 7 Office Visit: Examination and Coding © 2012 The McGraw -Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to:

7.1 Discuss the methods of entering documentation in an EHR. 7.2 Compare the process of entering a progress note with and without using a template. 7.3 Explain why e -prescribing reduces some medical errors. 7.4 List the steps required to enter a new prescription. 7.5 Explain why ordering and receiving test results electronically is more efficient than using paper methods. 7.6 List the steps required to enter an electronic order. 7 -2 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to:

7.7 Explain how orders are processed in an EHR. 7.8 Define medical coding. 7.9 Discuss the purpose of ICD -9 -CM. 7.10 Discuss the purpose of the CPT/HCPCS code sets. 7.11 Demonstrate the process that is followed to select a correct evaluation and management code. 7.12 Compare coding in a paper -based office with coding in an office with an EHR. 7.13 Discuss the purpose of an electronic encounter form in an EHR. 7 -3 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. Key Terms • Alphabetic Index • Category I codes • Category II codes • Category III codes • computer -assisted coding • Current Procedural Terminology (CPT) • dictation • digital dictation • electronic encounter form (EEF) 7 -4 • evaluation and management (E/M) codes • formulary • HCPCS • ICD -9 -CM • ICD -9 -CM Official Guidelines for Coding and Reporting • ICD -10 -CM • key components • medical coding © 2012 The McGraw -Hill Companies, Inc. All rights reserved. Key Terms (Continued) • primary diagnosis • SOAP • Tabular List • template • upcoding • voice recognition software 7 -5 © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.1 Methods of Entering Physician Documentation in an EHR 7 -6 • Dictation — process of recording spoken words that will later be transcribed into written form – Traditional method of documenting patient encounters • Digital dictation — process of dictating using a microphone, a headset connected to a computer, a smart phone, or a PDA • Voice recognition software — software that recognizes spoken words • Template — preformatted file that serves as a starting point for a new document © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.2 Progress Notes in Medisoft Clinical Patient Records 7 -7 • Progress notes can be entered using dictation and transcription, voice recognition software, or templates, or with a combination of techniques • SOAP — format used to enter progress notes; stands for subjective, objective, assessment, and plan © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.2 Progress Notes in Medisoft Clinical Patient Records (Continued) 7 -8 • To create a progress note:

– A patient chart must be open. – Click the Note button on the toolbar and enter the date and title. – Then choose from one of the documentation entry methods. – If using a template, it will be inserted in the note; the physician responds to its labels accordingly to complete the note. – If not using a template, the information is typed freely by the physician. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.3 E - Prescribing and Electronic Health Records 7 -9 • E -prescribing reduces some medical errors by: – avoiding many of the mistakes that occur with handwritten prescriptions, – providing a number of built -in safety checks, and – checking to be sure the medication is in the formulary of a patient’s health plan. • Formulary — list of a plan’s selected drugs and their proper dosages © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.4 Entering Prescriptions in Medisoft Clinical Patient Records 7 -10 To enter a new prescription in MCPR: – Start from the Rx/Medications folder in a chart, or click the Rx button; the Prescription dialog box will be displayed. – Complete the fields in the Prescription dialog box. – Review the ten check boxes in the dialog box. – Click the OK button to save the current prescription. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.5 Ordering Tests and Procedures in an EHR 7 -11 Electronic order entry is more efficient than paper methods as it:

– reduces errors associated with handwritten and paper orders, – provides numerous safety and cost -control benefits, – allows the user to delay sending out orders until approval is received, and – allows orders to be printed or transmitted electronically. • In addition, MCPR is capable of checking orders against information specific to a patient. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.6 Order Entry in Medisoft Clinical Patient Records 7 -12 • In MCPR, physicians can enter orders for laboratory, radiology, pathology, and other diagnostic tests. • To enter an electronic order in MCPR:

– Click on the Orders folder in the patient’s chart; the Orders dialog box is displayed. – Click the New button to enter a new order; the Order dialog box will open. – Complete the four sections of the Order dialog box. – Click OK to record the orders. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.7 Order Processing in Medisoft Clinical Patient Records 7 -13 • To process an order:

– In MPCR, select Orders > Order Processing on the Task menu; the Order Processing Select screen appears, with the Select Orders dialog box on top. – Use the filters in the Select Orders dialog box. – The Order Processing Select dialog box will display the orders that meet the criteria selected. – Click the Edit button to view an order before it is processed. – To print an order for a patient, click the Forms button; then click the OK button on the Standard Orders Printing Select dialog box which appears. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.7 Order Processing in Medisoft Clinical Patient Records (Continued) 7 -14 • To process an order (continued):

– To send an order electronically, right click the line that contains the order; a menu will appear. – Select the appropriate options from the menu. – Click the OK button to send the order. – Once the order has been printed or sent electronically, its status will change from pending to sent. – To view orders that have been sent, select Sent as the Order Status in the Select Orders dialog box. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.8 Medical Coding Basics 7 -15 • Medical coding — process of applying the HIPAA -mandated code sets to assign codes to diagnoses and procedures • In the physician practice coding environment, the required code sets are:

– CPT ( Current Procedural Terminology ) – HCPCS (Healthcare Common Procedure Coding System) – ICD -9 -CM ( International Classification of Diseases , Ninth Revision, Clinical Modification ) © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding 7 -16 • Primary diagnosis — patient’s major illness or condition for an encounter • ICD -9 -CM — abberivated title of International Classification of Diseases , Ninth Revision, Clinical Modification , the source of the codes used for reporting diagnoses – Used to code and classify morbidity data from patient medical records, physician offices, and national surveys © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding (Continued) 7 -17 • The ICD -9 -CM code set has three parts: – Diseases and Injuries: Tabular List — Volume 1 – Diseases and Injuries: Alphabetic Index — Volume 2 – Procedures: Tabular List and Alphabetic Index — Volume 3 • Tabular List — section of the ICD -9 -CM listing diagnosis codes numerically • Alphabetic Index — section of the ICD -9 -CM alphabetically listing diseases and injuries with corresponding diagnosis codes © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.9 Diagnostic Coding (Continued) 7 -18 • ICD -9 -CM Official Guidelines for Coding and Reporting — American Hospital Association publication that provides rules for selecting and sequencing diagnosis codes • ICD -10 -CM — abbreviate title of International Classification of Diseases , Tenth Revision, Clinical Modification , which will be used beginning in 2013 – Provides many more categories for disease and other health -related conditions and much greater flexibility for adding new codes © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.10 Procedural Coding 7 -19 • Procedure codes are used by physicians to report the medical, surgical, and diagnostic services they provide. • Current Procedural Terminology (CPT) — standardized classification system for reporting medical procedures and services • HCPCS — procedure codes for Medicare claims © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.10 Procedural Coding (Continued) 7 -20 • There are three categories of CPT codes:

– Category I codes — procedure codes found in the main body of CPT – Category II codes — optional CPT codes that track performance measures – Category III codes — temporary codes for emerging technology, services, and procedures © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.11 Evaluation and Management (E/M) Codes 7 -21 • Evaluation and management (E/M) codes — codes that cover physicians’ services performed to determine the optimum course for patient care • To select the correct E/M code, eight steps are followed:

– Step 1: Determine the category and subcategory of service based on the place of service and the patient’s status. – Step 2: Determine the extent of the history that is documented. – Step 3: Determine the extent of the examination that is documented. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.11 Evaluation and Management (E/M) Codes (Continued) 7 -22 • Selecting the correct E/M code (continued):

– Step 4: Determine the complexity of medical decision making that is documented. – Step 5: Analyze the requirements to report the service level. – Step 6: Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination. – Step 7: Verify that the documentation is complete. – Step 8: Assign the code. • Key component — factors documented for various levels of E/M services © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.12 Coding Methods 7 -23 • Coding in a paper -based office: – Provider writes or dictates notes either during or after the examination. – Written notes are filed in the patient’s chart; dictated notes must be transcribed and then reviewed for accuracy by the provider. – Coder reviews the provider’s documentation and assigns codes for the patient’s diagnoses and for the services provided. – Once codes are assigned, the encounter forms are forwarded to a billing department, where the staff manually enters the information into the PM system. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.12 Coding Methods (Continued) 7 -24 • Coding in an office with an EHR:

– Provider documents the visit in the EHR. – EHR assigns preliminary codes based on the documentation. – Coder reviews the EHR -generated codes for the patient’s diagnosis and for the services provided and assigns a diagnosis code to each procedure code. – Coder instructs the EHR to transmit the encounter information electronically to the PM system. © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.12 Coding Methods (Continued) 7 -25 • Computer -assisted coding — assigning preliminary diagnosis and procedure codes using computer software • Upcoding — assigning a higher level code than is supported by documentation © 2012 The McGraw -Hill Companies, Inc. All rights reserved. 7.13 Coding in Medisoft Clinical Patient Records 7 -26 Electronic encounter form (EEF) — electronic version of the form that lists procedures and charges for a patient’s visit – It eliminates the need for paper encounter forms. – It is automatically populated with preliminary codes derived from information in the progress note in the EHR. – Its codes are reviewed by a coding specialist.