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CHAPTER

McGraw-Hill

Office Visit: Examination and Coding

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

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

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

Teaching Notes: Many of these terms deal with coding, which might be a new topic for many students. As much as possible, explain the terms and provide examples so students can make connections.

OPTIONS: After you have gone over the basics of coding, have students/student groups research a set number of terms and present their findings to the class. Provide specific examples (of an instance of upcoding, for example) and see if students can match the examples to the correct terms.

Key Terms (Continued)

primary diagnosis
SOAP
Tabular List
template
upcoding
voice recognition software

7-5

Teaching Notes: See notes on Slide 4.

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

Learning Outcome: 7.1 Discuss the methods of entering documentation in an EHR.

Teaching Notes: Note that U.S. physicians create more than ONE BILLION clinical notes each year. Use this information to transition into a discussion of the benefits of an EHR.

Direct students’ attention to Figures 7.1, 7.2, and 7.3 in the text, which compare various ways for dictating and transcribing information. Discuss the advantages and disadvantages of each method.

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

Learning Outcome: 7.2 Compare the process of entering a progress note with and without using a template.

Teaching Notes: Present a selection of patient encounters, and give students (either individually or in groups) the assignment of creating a brief SOAP note for their assigned encounter. Discuss the results as a class.

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.

Learning Outcome: 7.2 Compare the process of entering a progress note with and without using a template.

Teaching Notes: Ask students to brainstorm the reasons behind using or not using a template – why would one be better than the other? What does it depend upon? Are there any drawbacks to using a template?

Us the figures from the text to show examples of what a progress note in MCPR looks like at various stages.

Have students complete Exercises 7.1-7.8.

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

Learning Outcome: 7.3 Explain why e-prescribing reduces some medical errors.

Teaching Notes: Ask students to think about how prescription safety checks and refilling were done before the days of e-prescribing. Use Figures 7.10 and 7.11 for assistance. What concerns are associated with the “old way”? Are there any benefits to doing safety checks without the benefit of technology? Ask: As a patient, would you rather your medicine be e-prescribed or checked and filled manually? Why?

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.

Learning Outcome: 7.4 List the steps required to enter a new prescription.

Teaching Notes:

Note that a PIN is needed to transmit prescriptions. Why?

MCPR monitors ALL patient prescriptions – new, ineffective, and historical (review those terms with students).

Point out the dose Calculator button, another Medisoft function that calculates doses based on patient weight and the 10 required check boxes that ensure prescription accuracy.

Have students complete Exercise 7.9.

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.

Learning Outcome: 7.5 Explain why ordering and receiving test results electronically is more efficient than using paper methods.

Teaching Notes: Explain that some EHRs have built-in standard order sets for common procedures, and while many large practices have lab facilities on-site, most small practices must outsource all of their lab work. Thankfully, if the practice uses an EHR, the EHR can receive lab results electronically.

Ask students to compare and contrast Figures 7.13 and 7.14. Which do they prefer? Why?

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.

Learning Outcome: 7.6 List the steps required to enter an electronic order.

Teaching Notes: Orders are automatically listed at the end of a progress note, if tests were ordered the same day a patient was seen.

Have students discuss why the “panel” option is a nice function – user can order a whole panel rather than multiple single tests. Relate these panels to those in CPT, Lab and Path code section.

Show students Figures 7.16 and 7.17 to point out the Order Tree.

Have students complete Exercise 7.10.

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.

Learning Outcome: 7.7 Explain how orders are processed in an EHR.

Teaching Notes: Walk students through the order processing process using the screenshots in the textbook for assistance and examples. Ask students why there appear to be so many steps to go through to process an order.

When discussing the Order Processing Select dialog box, identify all pieces of information that are displayed: date and time of order entry, patient name and ID, order name and status, PVID, order set, facility, and whether or not the order is a repeat.

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.

Learning Outcome: 7.7 Explain how orders are processed in an EHR.

Teaching Notes: See notes on Slide 13.

Have students complete Exercise 7.11.

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)

Learning Outcome: 7.8 Define medical coding.

Teaching Notes: Have sample coding books available, and let students page through them while discussing coding basics. Have students debate the pros and cons of using medical codes to classify diagnoses and procedures. Ask why the code sets are divided between diagnoses and procedures.

Discuss the fact that coding is directly tied to reimbursement. If possible, give examples of proper and improper coding and the results that come from each.

Give examples of coding scenarios and have students guess if the claim was reimbursed or not. Ask them to justify their thoughts.

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

Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM.

Teaching Notes: Explain to students that expertise in diagnostic coding requires knowledge of medical terminology, pathophysiology, and anatomy, as well as experience in applying coding guidelines. Ask students why a coder would need expertise in medical terms and pathologies in addition to coding knowledge.

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

Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM.

Teaching Notes: Explain to students which volumes (1 and 2) are for outpatient and which (3) is for inpatient coding. When might a coder use the tabular list versus the alphabetic list?

Reference Figure 7.22 in the text, which is a flowchart of the diagnostic coding process.

Discuss with the class the reasons for so many segmentations in use, type, and classification of ICD-9-CM codes.

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

Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM.

Teaching Notes: Note that the WHO put out the ICD-10 code set in 1990, but the United States is only now beginning the transition. Ask students to debate why the delay might have occurred and whether or not it was a good idea to stay with the ICD-9 for so long.

Ask students to put together a short research paper looking at the differences and challenges associated with ICD-9 and ICD-10; they should also look at the education/refreshers needed to aid in the transition.

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

Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS code sets.

Teaching Notes: Explain that procedure codes are used to help implement best practices; researchers track the results of various treatment plans and report them to physicians.

CPT = procedures and services
HCPCS (hick picks) = supplies and equipment

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

Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS code sets.

Teaching Notes: Give a number of examples of things that would fall into each code category so students can make connections. Then, call out various issues and procedures and see if students can properly categorize them (reducing tobacco use = Category II code).

NOTE: Explain that Category III codes may become permanent and part of the regular code set if the emerging service proves effective.

As an optional in-class assignment, have students use the Internet to research some Category III codes that have been added to the regular code set.

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.

Learning Outcome: 7.11 Demonstrate the process that is followed to select a correct evaluation and management code.

Teaching Notes: Explain that E/M codes are a subset of CPT codes; they reflect a range of analysis and decision-making, from low to high. (Provide examples to students to enhance connections). Each range is tied to an increasingly higher payment level.

Use the flowchart in the textbook (Figure 7.24) to illustrate the 8 steps of choosing an E/M code.

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

Learning Outcome: 7.11 Demonstrate the process that is followed to select a correct evaluation and management code.

Teaching Notes: Provide sample scenarios to student groups, and have each group walk through the 8 steps of determining and assigning the codes. Discuss results as a whole class.

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.

Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR.

Teaching Notes: The typical coding/billing/reimbursement cycle takes anywhere from 3-14 days. It is estimated that some practices lose up to 10% of revenue due to manual billing errors. Coding is done by a member of office’s coding staff.

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.

Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR.

Teaching Notes: Normally, some part of the process is automated. Turnaround is much quicker since the computer system flags a lack of information for determining code sets. The user can search for codes by entering keywords and information into the system.

Have students compare and contrast Figures 7.25 and 7.26. What differences do they see?

Be sure to cover the warnings for coding in an EHR office – risk for committing fraud (ask students how this is so), inaccurate code submission.

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

Learning Outcome: 7.12 Compare coding in a paper-based office with coding in an office with an EHR.

Teaching Notes: Assign students a short paper discussing the pros and cons of a paper-based coding system versus computer/EHR coding.

IMPORTANT: Stress the negative implications of upcoding, how it can be avoided, and whether or not it is always intentional.

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.

Learning Outcome: 7.13 Discuss the purpose of an electronic encounter form in an EHR.

Teaching Notes: Explain that MCPR’s coding function is employed after the EEF is completed and reviewed. Point out the Action Item tab in MCPR (reference Figure 7.29) and note that if there is an outstanding action item, a claim cannot be transmitted.

Ask students: If electronic coding is supposed to reduce errors, aid in reimbursement, and streamline the coding process, why does a coding specialist need to review all codes? Doesn’t that seem counterintuitive?

Have students complete Exercise 7.12.