2014 RPMS EHR HIM & Coding. David Taylor MHS, RPh, PA-C, RN DRAFT

Transcription

1 2014 RPMS EHR HIM & Coding David Taylor MHS, RPh, PA-C, RN 1

2 2014 RPMS HER CEHRT HIM & Coding Overview HIM Impact and Coding Lessons Learned SNOMED CT RPMS EHR Software Changes affecting HIM and Coding Integrated Problem List (IPL) and Impact on Coding 2

3 2014 RPMS EHR HIM Impact & Coding Prepared by Dujuanna Bissonnette, RHIT, CPC Phoenix Area HIM Consultant 3

4 Beta Test Lessons Learned (Special Thanks to Whiteriver & Gallup) Prepare Coding Staff Productivity Impact Inability to Edit Problem List Provider and Coder Impact FAQ s Workflow Considerations Policies and Procedures (How to complete a visit).9999 ICD-9 Code (do not delete) HIM Monitoring Error Reports Increased Frequency Problem List Cleanup of Utmost Importance PRB Fix Uncoded PROBLEM FILE Diagnosis Review Allergies on Problem List Report 4

5 HIM & Coding Considerations (Thank You Whiteriver and Gallup) Decrease in coding productivity CLEAN UP PROBLEM LIST Negative impacts downstream Aggressively monitor ERROR Reports to manage the increase in.9999 ICD Uncoded Family history can still be coded from TIU note although format is different Be aware of medico-legal impact of uncoded diagnoses (Fix Uncoded Diagnoses) DO NOT DELETE

6 HIM Supervisory Roles & Responsibilities in Preparing for RPMS EHR 2014 Monitor Coding productivity Train on RPMS EHR 2014 Test prior to Go- Live Standardize EHR GUI (Vuecentric) and TIU Templates to support Clinical Documentation consistency Review and revise abbreviations Educate Coding Staff on SNOMED Display in IPL and Coding Queue 6

7 HIM Roles & Responsibilities in Preparing for RPMS EHR 2014 CEHRT Clean up Problem List before conversion Fix Uncoded Problem File Diagnoses Identify CPT Superbills with ICD Associations to be Disassociated Export custom Pick Lists before conversion Review Pick List needs Review Configuration & Test EHR GUI (Vuecentric) Template on RPMS EHR Test Review & Revise Pharmacy Refill process for assigning POV Review Nursing Process for workflow and Clinical Documentation (eg Immunizations) 7

8 What is SNOMED CT? Systematized NOmenclature of MEDicine Clinical Terms (SNOMED CT ) is a comprehensive, multilingual clinical terminology that provides clinical content and expressivity for clinical documentation. Clinician friendly language to document clinical impressions, findings, and diagnoses. 8

9 Why the Change to SNOMED CT? 2014 Certified EHR requires: SNOMED CT for problem list Longitudinal problem-focused documentation including goals, care plans, and visit instructions SNOMED CT for much of the data used in Clinical Quality Measures Transition to ICD-10 - our goals are to: Stabilize the user interface in advance of ICD-10 changes Improve clinical documentation of problems and encounter diagnoses to support ICD-10 coding 9

10 SNOMED CT in the RPMS EHR Where will you see SNOMED CT? You will select SNOMED CT terms instead of ICD-9 or ICD-10 codes for diagnoses and conditions on the problem list, and clinical indications when ordering labs, medications, and consults. SNOMED CT codes will also be stored in the background in other areas of the EHR. 10

11 SNOMED CT in the RPMS EHR What does this mean for the clinical user? The most significant change is a redesigned and redefined problem list. The way problems are entered and managed and how POVs are selected has been changed. 11

12 SNOMED CT Related Maps Used in RPMS (cont.) SNOMED CT to ICD-9 provided by CMS and delivered by NLM Use in EHR for SNOMED problems and problems selected as POVs prior to ICD-10 transition 12

13 SNOMED to ICD-9 Mapping Examples SNOMED Term Sunburn of second degree Diabetic Nephropathy Ganglion of the wrist ICD-9 Sunburn of second degree Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Ganglion of joint Storage of Mapped Codes 1:1 This is a 1:1 match so will store in the POV when selected. 1:1: This is a 1:1 match so will store both ICD-9 codes. When problem is selected as POV, 2 POVs will store. Narrow to Broad: Closest ICD-9 code is less specific than the SNOMED. This will store in POV when selected. When there is no mapping available OR when the closest ICD-9 code is more specific than the SNOMED, then the system will assign.9999 un-coded. The code assigned by coders will depend on the SNOMED term selected and the remainder of the visit documentation. 13

14 Mappings to ICD Mappings are an integral part of the design of the Integrated Problem List and how SNOMED CT will assist IHS with the transition to ICD-10. These mappings automate, only when appropriate, assignment of ICD codes. Mappings are transparent to the user. They are visible when selecting a SNOMED, on the problem list, visit diagnosis, and clinical indications. 14

15 Assigning ICD Codes through EHR and Coding through PCC Coding Queue Provider selects SNOMED CT Problem and assigns as Purpose of Visit (POV) or Encounter Diagnosis Provider enters Provider Text for visit from POV Dialog (Optional) Coder reviews provider narrative, qualifier, and encounter notes. Coder accepts or changes mapped codes Coder assigns ICD Codes to uncoded entries and adds any additional codes supported by the Clinical Documentation Note: After conversion to ICD-10 an additional Map advice is passed through PCC to assist with ICD-10 transition 15

16 Why Can t I Edit Provider Narrative Provider narrative is stored as the SNOMED description ID (numeric value corresponding to the term the provider selected) Provider Text field is limited to 60 characters) and delimited by an Narrative is a standard term stored as a numeric value and therefore it not editable by data entry/coding. 16

17 Why Can t I Edit Provider Narrative Format: SNOMED CT term provider text Example: Standard Term Clinician Free Text Hyperlipidemia uncontrolled 17

18 Unmapped ICD Codes on Problem List Problem List = SNOMED Codes (unable to assign ICD Code to.9999) POV = ICD Codes Mappings to ICD are based on the specific SNOMED term Final assigned ICD Codes for POV are based upon the entire encounter documentation When ICD Code is assigned for POV the Problem List WILL NOT change (This is intentional) Note: Fix Uncoded Problem File Diagnoses PRIOR to conversion Note: Provider is unable to take action on uncoded Problem on Problem List 18

19 Provider Narrative Abbreviations Imbedded within SNOMED Term if to the left of and Coder is unable to edit A future SNOMED CT update removes these abbreviations Train and encourage provides to select synonyms without abbreviations 19

20 Two or More POVs with One Provider Narrative SNOMED Terms may require two or more ICD Codes to define the condition Example: Diabetic Nephropathy describes the Diabetes describes the Nephropathy V58.67 describes the Insulin Use 20

21 RPMS EHR 2014 Conversion Contingency Plans Provider access to Shadow Server during conversion for viewing Patient Health Information Contingency Plan drill for paper workflow process, data entry, and scanning PCC Encounter Form training & availability Inpatient Packet training & availability PCC Data Entry for data elements Scan PCC forms via Vista Imaging Please DO NOT make providers duplicate note 21

22 Hands-On Exercise RPMS EHR 2014 Preparation Use PRB Fix Uncoded PROBLEM File Diagnoses Menu to assign most appropriate ICD Code for available Narrative Use POV Fix Uncoded PURPOSE OF VISIT Diagnoses Menu to assign most appropriate ICD Code for available Narrative Generate PLAL Report Allergies on Problem List and examine appropriateness of those Allergies documented on Problem List Generate PCC Error Report and examine for Uncoded Diagnoses Compare and contrast HIM Monitoring Reports (see spreadsheet) for RPMS EHR 2014 CEHRT conversion 22

23 Questions and Discussion 23

24 2014 RPMS EHR Software Changes Impacting HIM Coding Prepared by Susan Richards, MSN RPMS EHR Federal Lead 24

25 Software Changes Many software changes were required for Meaningful Use 2014 Some of the changes in functionality are temporary and will be restored in EHRp14 and EHRp15

26 Problem Management Change Description Comments Problems are now encoded in SNOMED Immediate impact after install Impacts all users Care Planning can be documented Optional functionality Users must update ICD-9 and uncoded problems to SNOMED prior to editing or using as POV Consider engaging all clinicians (nursing, pharmacy, etc.) in conversion effort User may choose to add goals, care plan and visit instructions Clean up problem lists prior to deployment Remove duplicates Remove inappropriate problems Code uncoded when possible Does not need to be used right away and is optional. May better support existing workflows that are using TIU or other workarounds to capture this info

27 Problem Management Change Description Comments Priority is not visible on Problem List display Immediate impact after install Impacts all users Temporary issue User may not sort display by priority Restored in EHRp14

28 POV Assignment Change Description Comments POV assignment from SNOMED encoded problems on Problem List only Immediate impact after install Impacts all users who assign POVs Can no longer add POV from Historical Diagnosis component Can no longer add POV from pick list. Users must convert existing or add SNOMED encoded problem then select as POV. Can use SNOMED POV selection tool to select multiple problems. View only component now Future development to add back functionality is being considered Pick list Future development to add back functionality is being considered

29 CPT Superbill Change Description Comments No longer can create diagnosis associations to store as POV Immediate impact after install Impacts all users who assign POVs particularly Nursing for immunization entry Temporary issue Superbill association does not support POV assignment Restored in EHRp14

30 Pick Lists Change Description Comments Pick lists are used to populate Problems not POV s Immediate impact after install Impacts all users who add/update/edit problems Pick lists cannot be configured to display for certain users, clinics, disciplines Immediate impact after install Pick list configuration enhanced Optional functionality Users may access pick lists from main problem screen and add/edit dialogs The configuration tools are present but will not be honored until EHRp14. CACs should be judicious in importing/creating pick lists and use creative naming conventions for ease of use until EHRp14 Pick lists can be imported and edited Pick List items may be defaulted to specific status saving user clicks Restored in EHRp14 Encourage engagement of clinical staff in selecting and editing pick lists

31 Family History Change Description Comments Family History conditions are added as SNOMED. Existing entries should be transitioned to SNOMED. Immediate impact after install Impacts all users who use Family History. Transition of existing data can be done over time

32 TIU Business Rules for Expected Cosigners Change Description Comments TIU no longer honors any business rule that allows editing of a signed TIU note. Restricts any user except Privacy Act Officers and Chief MIS to amend documents. Result: Expected co-signers can no longer edit notes even if the business rule is configured. Immediate impact after install This was a change from the VA software. IHS will adopt this change.

33 Questions and Discussion 33

34 2014 RPMS EHR CEHRT Integrated Problem List & HIM Coding Impact Prepared by Dujanna Bisonnette, RHIT, CPC Phoenix Area HIM Consultant 34

35 Integrated Problem List MU Required Features SNOMED CT Problem List Care Planning Treatment Regimen elements for CQM 35

36 Integrated Problem List Reverse Mapping tool to assist with updating Problem List from ICD-9 to SNOMED Mapping to ICD-9 without user intervention Data entry can still adjust coding when necessary and if un-coded after selected for POV POV selection from Problem List POV selection dialog Patient Ed documentation Expanded statuses Nationally vetted pick lists 36

37 Integrated Problem List Get SCT Reverse Mapping Tool 37

38 Integrated Problem List POV Selection Tool with Options for Additional Care Planning and Patient Education Documentation 38

39 Integrated Problem List Care Planning and Patient Education Documentation 39

40 Integrated Problem List Pick List Examples 40

41 MU2 Data Captured by IPL Feature Problems: SNOMED CT encoded POV selected from problem: SNOMED CT passed to V POV Required for Performance Measure? No No Meets MU requirement MU2 rule, CQM data capture CQM data capture Goal Notes No MU2 rule, displays on CCDA Care Plan Notes No MU2 rule, displays on CCDA Visit Instructions No MU2 rule, displays on CCDA (CS) Tx/Regiment/Followup No CQM data capture Patient Education No CQM date capture, CCDA 41

42 Family History SNOMED CT for Family History Conditions 42

43 Family History Ability to document actual age of onset for documented conditions. Ability to note approximate for age of onset. 43

44 SNOMED CT encoded Two new statuses Smoking Status 44

45 Infant Feeding SNOMED CT encoded feeding choices Added secondary fluids if not exclusively breast or formula fed 45

46 Select POV from IPL Hands-on Exercise IPL and Coding Queue Find Problem with.9999 on Problem List and attempt to Remove Use Get SCT Reverse Mapping Tool to map ICD to SNOMED Use Picklist to update IPL and POV Enter Provider Narratives for POV Document Status Document Care Plan, Patient Goals, and Visit Instructions 46

47 Hands-on Exercise Miscellaneous Documentation Update Family History Update Infant Feeding (Breast and Secondary Fluids) Select SNOMED CT for Immunization Due Use CPT Superbill Tab to document CPT Code for appropriate immunization via CPT Immunization Superbill with Associations Examine for ICD Association 47

48 Hands-on Exercise PCC Coding Queue Examine Entire Documentation through PCC Coding Queue Code any and all POVs containing.9999 ICD Code Examine POV Provider Narrative and attempt to Edit Examine Problem List and attempt to assign an ICD Code Enter Family History through Coding Queue 48

49 Questions and Discussion 49