Health Informatics: Week 4

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CHAPTER

7 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

Key Terms (Continued)

• primary diagnosis

• SOAP

• Tabular List

• template

• upcoding

• voice recognition

software

7-5

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

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

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.

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

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.

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.

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.

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.

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.

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)

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

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

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

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

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

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.

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

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.

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.

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

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.