1. Diagnosing (Physician) Chapter 15

2.  Add a diagnosis to a patient Objective

3.  Diagnosing  ICD-9  ICD-10  International classification of Diseases  World Health Organization(WHO) Key Concepts

4.  Identifying the condition/symptom that is reason for patient’s visit-key responsibility of physician  Physician must diagnose the patient’s problem into a converted ICD code in order to submit to payer for payment of services Diagnosing

5.  International Classification of Diseases  Have been used in US since 1900  Have been ten revisions of codes since inception  Physicians have been using ICD-9 to report their diagnoses since 1079  ICD-10 adopted for reporting mortality(causes of death) on January 1, 1999, but ICD-9 still used for morbidity(health conditions) ICD Codes

6.  Mandatory adoption date for ICD-10 is October 1, 2014  At this point all physicians will be required to use ICD-10 for both mortality and morbidity reporting  Electronic software companies must also adopt ICD-10 by this deadline  ICD codes (both 9 & 10) are provided and maintained by World Health Organization (WHO)  There are more than 14,000 ICD-9 codes but new code set expands it to over 68,000 ICD-10 codes  Increasing the specificity of physician diagnosis coding ICD-10

7.  Description-entering words to describe diagnosis  ICD code-entering code if known  Checklists-based on presenting problems selected  Tree structure-starting at top of diagnosis tree  Problem-based on presenting problem  Body part-based on body part(s) affected  Top 60 diagnoses MedTrak enables physician to select diagnosis for patient in many ways

8.  Once physician has examined patient  He/she will decide on patient’s diagnosis  These diagnoses may/may not coincide with what patient indicated to front desk person  Diagnoses determine what history/exam /aftercare questions physicians need to use for documenting patient’s visit  Alignment of history/exam/aftercare questions are another part of MedTrak’s problem-focused functionality  Diagnosis process facilitates clinical decision support (CDS) rules which comply with Meaningful Use Core Objective 11  Do This! Pg. 190 Patient Diagnosis

9.  Cursor in Diagnosis field of Visit Documentation screen(Figure 15-1)  Click DX by Checklist button to display Add Diagnosis screen  Note appears at top of screen identifying presenting problem(Figure 15-2)  Add Diagnosis screen functions just like Order Entry screen  Plus sign indicates there are more selections available  Green cross indicates these are selectable diagnoses  Minus sign at top line indicates there are more diagnoses by going up the diagnosis tree(Figure 15-3) Selecting A Diagnosis Based On The Presenting Problem

10.  After selecting diagnosis click Exit screen button to return to Visit Documentation screen  ICD-9 code is displayed with description(Figure 15-4)  Select diagnosis by using MedTrak Diagnosis Tree  MedTrak attaches ICD codes to diagnosis descriptions  When diagnosis is selected ICD code is automatically loaded for documentation and billing purposes  There could be multiple diagnoses needed for patient’s encounter-you can select all of the applicable diagnoses.  When required MedTrak will replace ICD-9 with ICD-10 code set Selecting Diagnosis

11.  Another diagnosis search function:  FIND DX by Description  Click on Find DX button on Visit Documentation screen  Diagnosis: Find screen appears  Enter diagnosis description in Description field(Figure 15-5) Selecting A Diagnosis Based On The Description

12.  Click Submit button  Add DX by Description screen appears to select  Type diagnosis description words in any order  Add DX by Description screen refreshed with message “Adding:…….(your description)” at top of screen  If patient has anther diagnosis type the next description in Search field and click the Search button  When done click Exit Screen button to return to Visit Documentation screen(Figure 15-7)  Screen will list selected diagnoses in the Diagnosis section.  To delete diagnosis, place cursor next to diagnosis that needs deleting and click Delete DX button  Do This! Pg. 195 & 196 Selecting A Diagnosis Based On The Description