1. PCC Data Entry Coding Que Albuquerque Area Office Coding Que Training 1/18/07 – 1/19/07

2. Turning on the Coding Que When does my site need to turn coding que on? As soon as you turn on paperless refill you need to turn on the coding que What date should my site use when turning on the coding que? Use the same date that you use when you turn on paperless refill. Where does my site turn on the coding que? See HIM/BO setup power point Who is responsible for turning on the coding que? Site manager, CAC, Data Entry Supervisor Must communicate with Pharmacy or CAC in order to determine when they will implement paperless refill or documenting in EHR

3. Patient Care Component (PCC) Data Entry Coding Que Captures ALL electronically created visits into a holding que Prevents visits not reviewed by data entry from passing directly to the billing package Visits captured include: Paperless Refills ALL EHR created visits

4. PCC Data Entry Module How do I get to the Coding Que Menu? 1.PCC 2.PCC Management Reports (PCC) 3.Enter/Modify/Append PCC Data (ENT) 4.EHR/PCC Coding Audit Menu (EHRC)

5. EHR/PCC Coding Audit Menu What is the difference between the coding que reports? EHRD EHR/PCC Coding Audit for Visits in Date Range PEHR EHR/PCC Coding Audit for One Patient TUR Count Unreviewed Visits by Date/Service Category LIR List Unreviewed/Incomplete Visits

6. EHRD Visit by Date Range

7. (EHRD) Visit by Date Range Used to audit visits that are created by EHR users Visit display in list are those with an INCOMPLETE or blank chart audit status List can be sorted by date, primary provider, clinic code, hospital location (scheduling clinic), & facility

8. Once the visit is reviewed, the reviewed status can be set to: Reviewed/Complete Incomplete All visits set as reviewed/complete will be passed to the IHS/RPMS billing package A visit will NOT pass to billing until it is marked reviewed/completed (EHRD) Visit by Date Range

9. Incomplete/Orphan ancillary visits: Will NOT appear on the EHRD report list These visits will show up on the LIR and the PPPV reports This type of visits will need to be completed and flagged as complete through the normal data entry process (EHRD) Visit by Date Range

10. Visits with the following service categories are included in the visits (A) Ambulatory (T) Telecommunications (I) In Hospital (S) Day Surgery (C) Chart Review (O) Observation (R) Nursing Home (EHRD) Visit by Date Range

11. How do I run the EHRD report? Limit your date range to 7 days or less 1 st Select the FACILITY (A) All Locations/Facilities (S) Selected set or Taxonomy of Locations (O) ONE Location/Facility 2 nd Select a CLINIC (A) All Clinics (S) Selected set or Taxonomy of Clinics (O) One Clinic (EHRD) Visit By Date Range

12. 3 rd Select Hospital Locations (A) All Hospital Locations (S) Selected set of Hospital Locations (O) ONE Hospital Location 4 th Select Providers (A) ALL Providers (S) Selected set or Taxonomy of Providers (O) ONE Provider

13. (EHRD) Visit By Date Range 5 th Select Visit Based on Chart Deficiency Reason (D) Do NOT screen on Chart Deficiency Reason (S) Screen on Chart Deficiency Reason

14. (EHRD) Visit By Date Range 6 th Sort Visit: (N) Patient Name (H) HRN (D) Date of Visit (T) Terminal Digit of HRN (S) Service Category (L) Location of Encounter (C) Clinic (H) Hospital Location (P) Primary Provider (A) Chart Audit Status (R) Chart Deficiency Reason (Last one entered) (I) Has Medicare/Medicaid or PI

15. (EHRD) Visit By Date Range An asterisk’s beside the number indicates that data is missing from the visit By using the right arrow key you can scroll to the right side of the screen to see what data is required before the visit can be completed Possible reason’s for seeing an asterisk’s includes: NO POV 9999 Code Missing Provider

16. (EHRD) Visit By Date Range More Actions Display Visit – display the data captured from the electronic order entry Note Display – view the EHR note Modify Visit – allows Coders to EDIT data already in the electronic visit Append to Visit – allows Coders to add NEW data to the electronic visit

17. More Actions cont….. Visit Merge – allows Coders to merge orphan visits w/ primary visit Status Update – up date visit from unreviewed/incomplete to reviewed/complete Resort List Chart Audit History – Displays reason’s why visit has not be been reviewed/completed Health Summary – Displays patients health summary One Patient’s Visits – Displays individual patient visits Visit Delete (EHRD) Visit By Date Range

18. PEHR Audit for One Patient

19. (PEHR) Audit for One Patient Used to review visits created by EHR users for ONE patient Visits displayed in list are those with an INCOMPLETE or BLANK audit status List can be sorted by date, primary provider, clinic code, hospital location (scheduling clinic), and facility Visit must be reviewed before they will pass to the IHS/RPMS billing package

20. (PEHR) Audit for One Patient Visits with the following service categories are included in the visits (A) Ambulatory (T) Telecommunications (I) In Hospital (S) Day Surgery (C) Chart Review (O) Observation (R) Nursing Home

21. (PEHR) Audit for One Patient Select Patient Name Sort visit by: Date of Visit Service Category Location of Encounter Clinic Hospital Location Primary Provider Chart Audit Status Chart Deficiency Reason (Last one entered)

22. TUR Count Unreviewed Visits

23. (TUR) Count Unreviewed Visits Reports a count of all visits with a chart audit status of incomplete or blank Visits can be selected and sorted by: Date Primary provider Chart audit status. Contract Health Visits are EXCLUDED

24. Visits included in TUR: Ambulatory Day Surgery Observations Telecommunications Chart Review (TUR) Count Unreviewed Visits

25. Select Facility (A) ALL Locations/Facilities (S) Selected set or Taxonomy of Locations (O) Location/Facility Select Clinic (A) ALL Clinics (S) Selected set or Taxonomy of Clinics (O) ONE Clinic (TUR) Count Unreviewed Visits

26. Select Hospital Location (A) ALL Hospital Locations (S) Selected set of Hospital Locations (O) ONE Hospital Location Select Provider (A) ALL Providers (S) Selected set or Taxonomy of Providers (O) ONE Provider (TUR) Count Unreviewed Visits

27. Select Chart Deficiency Reason (D) Do NOT screen on Chart Deficiency Reason (S) Screen on Chart Deficiency Reason Select Chart Deficiency Reasons See EHRD Chart Deficiency Reasons for list (TUR) Count Unreviewed Visits

28. Report will list: Service category # of unreviewed Visits # with No Provider (Ancillary) (TUR) Count Unreviewed Visits

29. LIR List Unreviewed/Incomplete Visits

30. LIR List Unreviewed/Incomplete Visits Reports all visits with a chart audit of incomplete or blank Visits can be sorted by: Date Primary provider Clinic code Hospital location (scheduling clinic) Facility

31. Visits with following service categories are included: Ambulatory Day Surgery Observation Telecommunications Chart Review Select Facility Visits Select Clinic (IHS Clinic Codes) visits Select F LIR List Unreviewed/Incomplete Visits

32. CHART AUDIT HISTORY

33. Chart Audit History If coder has reviewed visit and data is NOT ready to be completed the coder can mark the chart INCOMPLETE Marking the chart incomplete will allow the coder to revisit the chart again in the future and will prevent the file from going to the billing side prematurely

34. Chart Audit History Abnormal Laboratory Blood Transfusion Cause of Injury Chief Complaint Consent Form Consultation Report CPT Codes Date of Visit DICT OP Report Documentation for Procedures E&M Code by Provider EKG Code by Provider EKG Report ER Condition of Discharge ER Discharge Time ER Disposition ER Means of Arrival ETOH/Employment Related HCPCS Codes Chart Deficiency Reasons cont…

35. Chart Audit History History & Physical Initials for Immunizations GIV Initials for Pelvic Exam IV Flow Sheets Lab POV Nursing Assessment Other Pathology Report Pediatric Record Problem List Updates Progress Notes Purpose of Visit Sign OP Report Sign PCC Form – Nursing Sign PCC Form – Pharmacy Sign PCC Form – Primary Provider Time of Visit Transaction Code Unacceptable Abbreviations Vital Signs Chart Deficiency Reasons cont…

36. Complete Electronic Chart Review Review PCC Data Entry Reports including coding que reports Review all electronic health record data IF still using paper – review

37. Daily Reports EHRD report LIR report Uncoded Diagnosis report

38. Coding Que Recommendations All visits should be completed REGARDLESS if they are billable or not When documenting chart deficiency reasons do NOT select OTHER Not enough information for other coders or supervisors reviewing incomplete visits in the future.

39. Data Track Onsite Coders need to review the components they normally enter Once completed the coder will need to mark the chart incomplete and designate a chart deficiency reason before Data Track can complete their side of the chart review Data Track will be responsible for completing the review before visit can be sent to billing

40. Downside to NOT maintaining Coding Que Increased 9999 codes Missing provider Missing POV Missing CPT

41. Communication Data Entry needs to communicate with Clinical Applications Coordinator if issues/errors become repetitive CAC needs to inform Data Entry when new providers or clinics go live with EHR so they can review their data daily Data Entry needs to work with users to teach them how to code correctly and efficiently

42. Questions?