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Coding and AHLTA

VIEWS: 24 PAGES: 42

									 The Interaction between
Documentation and Coding
      within AHLTA
     MAJ Jacob Aaronson, DO
   Army OTSG, Office of the CIO

         UBU Conference
          15 March 2006
                           Overview
 • Clinical Perspective
 • Business Perspective
 • Relationship between structured data and
   accurate E&M
 • AHLTA coding capabilities
        – Existing
        – Future enhancements
 • Demonstration
                           jacob.aaronson@us.army.mil   2
15 March 2006   Slide #2
                                      V2.1
                           Clinical Perspective
 • EMR should facilitate clinical workflow
        – Byproduct of comprehensive documentation
          should be accurate coding
 • EMR should provide coding “decision
   support”
        – Clinician focus is patient care, not coding
 • Effective feedback loop with coding
   community is a necessity
 • Automation cannot improve process
                                jacob.aaronson@us.army.mil   3
15 March 2006   Slide #3
                                           V2.1
            Understanding and Improving
                 Coding in AHLTA
                “The short course”




                           jacob.aaronson@us.army.mil   4
15 March 2006   Slide #4
                                      V2.1
                   SOAP                                    MEDCIN

                                                           HPI Tab

                Subjective
                                                          PFSH Tab

                                                           ROS Tab


                 Objective                       Physical Exam (PE Tab)



                Assessment
                                                          A/P Module

                     Plan


                             jacob.aaronson@us.army.mil                   5
15 March 2006   Slide #5
                                        V2.1
         SOAP                        MEDCIN                 E/M Calculation

                                     HPI Tab                 HPI Elements
      Subjective
                                    PFSH Tab                PFSH Elements

                                     ROS Tab                   ROS
                                                         (Number of Systems)
                                                                   +
       Objective            Physical Exam (PE Tab)               PE Tab
                                                            (Specific Elements
                                                             And Effected by
                                                              Type of Exam,
    Assessment                                                Patient Status)
                                   A/P Module                      +
                                                               Diagnosis
           Plan
                                                        (Medical Decision Making –
                                                            Algorithm Based)
                           jacob.aaronson@us.army.mil                        6
15 March 2006   Slide #6
                                      V2.1
                           Background
 • Many user do not understand the previous relationships
 • Issue – Many users complain about the “speed” of
   documentation with AHLTA and its ability for multiple
   people to enter information into the note.
        – Speed – The time it takes to complete the entire healthcare
          encounter from check in to a completed note.
        – Training – Usually focuses on capabilities of the system NOT
          how to use AHLTA to improve healthcare delivery and your
          workday.
        – Documentation – A team responsibility
 • Solution – The best way to improve speed and
   effectiveness is to understand how AHLTA assists in the
   process of care and how this relates to business of
   care.
                             jacob.aaronson@us.army.mil                  7
15 March 2006   Slide #7
                                        V2.1
                               Scenario 1

 • OUTCOME – Multiple entries during a single encounter where
   separate time/date stamps are needed.

 • Nurse/Tech writes initial note or enters serial notes.
 • Provider writes ADDITIONAL note(s) that are emitted separate from
   the Nurse/tech‟s note.
 • All entries into the encounter stored in chronologic order.

 • Use Cases
        – Note started by Triage Nurse in Emergency Department
        – Documentation of Serial exams
        – Nursing documentation of intervention (IV fluids, nebulizer treatment,
          medication during the visit)
        – Transition of care between provider (i.e. Change of shift)



                                jacob.aaronson@us.army.mil                         8
15 March 2006   Slide #8
                                           V2.1
Scenario 1:
Here is the technician‟s note.
Subjective information is
collected for the provider or
it could be someone doing
triage.




                                 jacob.aaronson@us.army.mil   9
   15 March 2006   Slide #9
                                            V2.1
The provider or second person clicks
the S/O Button, and this is the window
presented. If the provider wants to just
add an additional entry to the note, then
the provider should click, „New Note‟.




                                 jacob.aaronson@us.army.mil   10
   15 March 2006   Slide #10
                                            V2.1
Note the technician‟s note is
intact above the doctors
note. The provider‟s or
second person‟s entry has a
new signature and time/date
stamp.




                                jacob.aaronson@us.army.mil   11
   15 March 2006   Slide #11
                                           V2.1
                            Scenario 2
 • OUTCOME
        – Provider wants to leverage the data/information that the
          Tech/Nurse has gathered.
        – Provider takes over the tech/nurses note (edit) and the
          tech/nursing note shows up at the bottom of the page (for
          auditing purposes).
 • Tech/Nurse documents initial data and an initial note is
   generated.
 • Provider assumes responsible for the encounter and
   completes the encounter with a single time data stamp.
   This makes a more legible note for the next person to
   read – as well as allows the sharing of data entered.

 • Use Case: Typical Office Visit (at least the start of one).

                             jacob.aaronson@us.army.mil               12
15 March 2006   Slide #12
                                        V2.1
Scenario 2:
Here is the technician‟s note. Subjective
information is collected from the patient as
agreed by the healthcare team.




                                  jacob.aaronson@us.army.mil   13
   15 March 2006   Slide #13
                                             V2.1
The provider clicks the S/O
Button, and this is the
window presented.
Provider click‟s edit note.




                                jacob.aaronson@us.army.mil   14
    15 March 2006   Slide #14
                                           V2.1
Note: Try hard to avoid reading this
   pop-up (as it is very confusing),
1. Just click „No‟.
2. You will get another pop-up.




                                  jacob.aaronson@us.army.mil   15
    15 March 2006   Slide #15
                                             V2.1
Provider: Now click „Yes‟




                               jacob.aaronson@us.army.mil   16
   15 March 2006   Slide #16
                                          V2.1
Provider completes S/O portion of note with their default encounter
template or AIM form.
The result of this is just one S/0 note - the provider‟s note - and the
information entered by the nurse/technician‟s is moved to the change
history.




                                 jacob.aaronson@us.army.mil               17
   15 March 2006   Slide #17
                                            V2.1
                    Business Perspective
 • Documentation should clearly and
   accurately support E&M, ICD, CPT coding
 • With an EMR capable of coding, the role
   of a coder shifts to auditor
 • Effective feedback loop with clinical
   community - focused on areas with ROI -
   is a necessity


                            jacob.aaronson@us.army.mil   18
15 March 2006   Slide #18
                                       V2.1
                 The Macro View of
                      AHLTA:
           Structured Term Use per E&M
               E&M Code Distribution
                 Productivity Impact
                            3.3 Million Encounters
                           8/21/2005-11/26/2005
                             Data Source: CDR
      Note: Data is raw data from provider visit without coder review or
                                intervention.
                               jacob.aaronson@us.army.mil                  19
15 March 2006   Slide #19
                                          V2.1
                                                                          0
                                                                              20
                                                                                   40
                                                                                        60
                                                                                             80
                                                                                                  100
                                                                                                        120
                                             Across All EandMCodes
                                                 Est Outpt Visit, Lvl 1
                                                 Est Outpt Visit, Lvl 2
                                                 Est Outpt Visit, Lvl 3




        15 March 2006
                                                 Est Outpt Visit, Lvl 4
                                                 Est Outpt Visit, Lvl 5
                                                New Outpt Visit, Lvl 1
                                                New Outpt Visit, Lvl 2




        Slide #20
                                                New Outpt Visit, Lvl 3
                                                New Outpt Visit, Lvl 4
                                                New Outpt Visit, Lvl 5
                                                 Outpt Consult, Lvl 1
                                                 Outpt Consult, Lvl 2
                                                 Outpt Consult, Lvl 3
                                                 Outpt Consult, Lvl 4
                                                 Outpt Consult, Lvl 5
                                          Emergency Dept Visit, Lvl 1
                                          Emergency Dept Visit, Lvl 2
                                          Emergency Dept Visit, Lvl 3
                                          Emergency Dept Visit, Lvl 4
                                          Emergency Dept Visit, Lvl 5




           V2.1
                                   Initial Comp Prev Med Eval, <1 y.o.
                               Initial Comp Prev Med Eval, 12-17 y.o.
                                  Initial Comp Prev Med Eval, 1-4 y.o.
                               Initial Comp Prev Med Eval, 18-39 y.o.
                                                                                                              (may be calculated or selected by user)




                               Initial Comp Prev Med Eval, 40-64 y.o.




jacob.aaronson@us.army.mil
                                 Initial Comp Prev Med Eval, 5-11 y.o.
                                 Initial Comp Prev Med Eval, 65+ y.o.
                                                                                                                                                        Average # of Medcin Terms per Encounter by E&M code




                                Periodic Comp Prev Med Eval, <1 y.o.
                             Periodic Comp Prev Med Eval, 12-17 y.o.
                               Periodic Comp Prev Med Eval, 1-4 y.o.
                             Periodic Comp Prev Med Eval, 18-39 y.o.
                             Periodic Comp Prev Med Eval, 40-64 y.o.
                              Periodic Comp Prev Med Eval, 5-11 y.o.
                              Periodic Comp Prev Med Eval, 65+ y.o.
                        Administer/Interpret Health Risk Assessment
                                      Unlisted Prev Medicine Service
                                          Confirmatory consult, Lvl 1
                                          Confirmatory consult, Lvl 2
                                                                                                                                                                                                              # MEDCIN Terms in S/O vs. E/M Code




                                          Confirmatory consult, Lvl 3
                  20
                                                                                                                                                                   All Services




                                          Confirmatory consult, Lvl 4
                                          Confirmatory consult, Lvl 5
                            jacob.aaronson@us.army.mil   21
15 March 2006   Slide #21
                                       V2.1
                            jacob.aaronson@us.army.mil   22
15 March 2006   Slide #22
                                       V2.1
                            jacob.aaronson@us.army.mil   23
15 March 2006   Slide #23
                                       V2.1
        Comparison of AHLTA FP Est. Outpatient Visit E&M
         Code Distribution to Medicare and Recommended
                             Distribution




                            jacob.aaronson@us.army.mil     24
15 March 2006   Slide #24
                                       V2.1
                            jacob.aaronson@us.army.mil   25
15 March 2006   Slide #25
                                       V2.1
       MTF Productivity and Access
       AMEDD AHLTA Use Impact
                            FY 04 and FY 05
                            Data Source: PASBA




                             jacob.aaronson@us.army.mil   26
15 March 2006   Slide #26
                                        V2.1
                Encounters/FTE from FY04-05
                                                               (From B MEPRS Clinics)
           5000

           4500

           4000

           3500                                                                                                                                                                                             05 Avg


           3000                                                                                                                                                                                             04 Avg



           2500

           2000
                              12 mo




                                                                                                                                                                                     12 mo
                                                                                                                  10 mo


                                                                                                                               12 mo
                                                    12 mo
                                            10 mo




                                                                                        10 mo




                                                                                                                                                        12 mo
                                                            12 mo


                                                                           12 mo




                                                                                                       12 mo




                                                                                                                                                                                                    12 mo
                                                                                                                                                                                             1 mo
                                                                                                7 mo




                                                                                                                                          9 mo
                                                                                                                                                 2 mo




                                                                                                                                                                        9 mo
                                                                    3 mo




           1500
                                                                     Gordon


                                                                                                 Lee




                                                                                                                                                                               Redstone
                                                                                                                                                                Wainwright
                                      Campbell
                         Benning


                                                      Eustis




                                                                                                               Polk




                                                                                                                                                                                              Bliss
                                                                                                                                       Sill
                                                                                   Jackson




                                                                                                                          Rucker


                                                                                                                                                  Stewart
         FY04
         FY05
        * Numbers in each column indicate the months using AHLTA during that FY
                                                                      jacob.aaronson@us.army.mil                                                                                                              27
15 March 2006     Slide #27
                                                                                 V2.1
                        RVUs/FTE from FY04-05
                                                              (From B MEPRS Clinics)
          4000

          3500

          3000
                                                                                                                                                                                05 Avg

                                                                                                                                                                                04 Avg
          2500

          2000

          1500
                             12 mo




                                                                                                                                                               12 mo
                                                                                                10 mo


                                                                                                             12 mo
                                                   12 mo
                                           10 mo




                                                                              10 mo




                                                                                                                                                                       1 mo
                                                                                      7 mo




                                                                                                                        9 mo
                                                                                                                               2 mo




                                                                                                                                                  9 mo
                                                               3 mo




          1000
                                                                Gordon




                                                                                             Polk
                                     Campbell
                        Benning


                                                     Eustis




                                                                                                                                                         Redstone
                                                                                                                                                                        Bliss
                                                                                                                     Sill


                                                                                                                                          Wainwright
                                                                                                        Rucker
                                                                         Jackson
                                                                                       Lee




                                                                                                                                Stewart
         FY04
         FY05
        * Numbers in each column indicate the months using AHLTA during that FY
                                                                 jacob.aaronson@us.army.mil                                                                                       28
15 March 2006    Slide #28
                                                                            V2.1
                            Conclusion
 • There is a general expected correlation between
   the number of MEDCIN terms used and the
   resulting E/M code through level 4 E&M codes
 • The E/M distribution pattern from AHLTA use is
   as expected and consistent across services
 • AHLTA implementation has occurred
   simultaneously with an increase in provider
   productivity.


                            jacob.aaronson@us.army.mil   29
15 March 2006   Slide #29
                                       V2.1
                            Recommendation
 • Focused analysis on MEDCIN term use to improve
   education on note writing (Status: In progress)
 • Continue trending MTF productivity but publicize present
   finding to change myths.
 • Evaluate need to change the present E/M “accuracy”
   metric and instead focus on E/M distribution level
 • Evaluate coder utilization and cost in AMEDD against
   ROI with plan to focus coding expenses on areas with
   known ROI
 • Need to insure all data captured in AHLTA is sent
   and accepted by SADR


                               jacob.aaronson@us.army.mil   30
15 March 2006   Slide #30
                                          V2.1
                            Common Errors
                             within AHLTA
 • E&M under-coding can occur with AHLTA. This is most
   commonly due to inappropriate use of free text or using a
   template that was not designed to accommodate optimal
   documentation resulting in a higher code.
 • Failure to use a Vcode for physicals and to select a Prev Med
   Eval/MGT Services Type for the visit in the Disposition
   Module.
 • Failure to select the proper EXAM TYPE for subspecialty
   areas in the Disposition Module.
    – Example: The coding rules change for ENT-specific exam
      vs. a general medical exam.
 • Failure to document common office procedures (CPTs) that
   were done (Pulse ox, EKG, immunization, etc)
 • Failure to use modifier codes with visits (such as a -25
   modifier when a patient comes in for two distinct problems)
                              jacob.aaronson@us.army.mil      31
15 March 2006   Slide #31
                                         V2.1
                AHLTA Coding Capabilities
                       Existing
 • S/O capture of Medcin terms
        – Templates
        – AIM forms
                                                         Encounter
 • A/P                                                   Templates
        – Diagnoses
        – Procedures
 • Disposition module

                            jacob.aaronson@us.army.mil               32
15 March 2006   Slide #32
                                       V2.1
                            jacob.aaronson@us.army.mil   33
15 March 2006   Slide #33
                                       V2.1
                            jacob.aaronson@us.army.mil   34
15 March 2006   Slide #34
                                       V2.1
                            jacob.aaronson@us.army.mil   35
15 March 2006   Slide #35
                                       V2.1
                AHLTA Coding Capabilities
                    Enhancements
 • Set E&M user defaults – (have a direct bearing
   on the calculated value for the E&M code)
        – Setting and Service Type
                • Control the overall category of E&M codes that will be used
                  in the calculation
        – Exam type
                • Can adjust the level calculated for the Physical Exam
                      – (only relevant to the “1997 Guidelines” for E&M calculation--the
                        guidelines that are currently utilized in the E&M calculator in
                        AHLTA)



                                    jacob.aaronson@us.army.mil                        36
15 March 2006    Slide #36
                                               V2.1
                   AHLTA Coding Capabilities
                       Enhancements
 •        Automated inclusion of certain encounter data
          in E&M and procedure coding:
        –       Pulse Ox, Peak Flow, visual acuity - automatically
                populate the appropriate CPT in A/P module
        –       All Vital Sign data included in the E&M Calculation
        –       AutoCited Problem List and Family History
                information included in the E&M Calculation
        –       All diagnoses to be included in the Medical Decision
                Making (MDM) component of the E&M Calculation
        –       Orders information to be included in the MDM
                component of the E&M Calculation.

                             jacob.aaronson@us.army.mil            37
15 March 2006   Slide #37
                                        V2.1
                   AHLTA Coding Capabilities
                       Enhancements
 •        “V code use” and MDM changes:
        –       Prompt the user for proper “V Code” use for
                Preventive Medicine Evaluation visits
        –       Simplify the method by which a provider may
                override the MDM component of the E&M
                calculation.. (as appropriate)
 •        Coding information resource links include the
          following:
        –       Addition of Government-specified coding resource
                web site links into the favorites list in the Web
                Browser module of the application.

                             jacob.aaronson@us.army.mil             38
15 March 2006   Slide #38
                                        V2.1
                   AHLTA Coding Capabilities
                       Enhancements
 •        Integrated Immunizations
               Capability to provide coding support and
                documentation for workload credit when
                immunizations are documented in the
                Immunization module.
               Capability to save procedures associated to
                immunizations to the A&P Module.



                            jacob.aaronson@us.army.mil    39
15 March 2006   Slide #39
                                       V2.1
                            AHLTA and Coding
 • Continue to analyze MEDCIN term use to improve
   education on note writing
 • Focus on E/M Distribution Reports instead of E/M
   “accuracy” metric
 • Automate E&M coding user defaults and enhancements
 • Understand and use modifiers
 • Document procedures
 • Improve processes
        –   “Immunization” clinics
        –   Linkage of work (RVU) to encounter and provider
        –   Healthcare team documentation
        –   Refine coder support

                                jacob.aaronson@us.army.mil    40
15 March 2006   Slide #40
                                           V2.1
Demonstration
                            jacob.aaronson@us.army.mil   42
15 March 2006   Slide #42
                                       V2.1

								
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