Coding in AHLTA & AHLTA Template Mgt

1. Coding in AHLTA & AHLTA Template Mgt Navy Medicine East Coding Supervisor Training – Jan 27-28, 2009 Hank Rogers, AHLTA Consultant

2. AGENDA • Documentation & Coding in AHLTA to Maximize RVU’s • E/M Calculator In Disposition Module • Usability Aim Form & Template Tips • New Templates to Maximize RVU’s • E/M Report in AHLTA • Questions/Answers

3. Documentation & Coding in AHLTA Maximizing RVU’s in the S/O

4. Warning!!!!Free Text used in AHLTA is NOT coded automaticallyAvoid using free textIf you must use it always try to associate it with a Medcin term

5. Free Text Said a Lot and Got NOTHING!!

6. No matter what you must have a CHIEF COMPLIANT

7. The history section of the S/O in AHLTA is divided into three distinct sections: • Past medical history • Family medical history • Social history

8. ALWAYS Add PMH Reviewed Just adding the PMH Reviewed gives one point

9. Two Levels of Service • According to the 1997 CMS Guidelines, there are only two levels of service for the PFSH component: “pertinent” and “complete”

10. ROS

11. The 1997 Guidelines identify 14 distinct body systems for the purposes of the Review of Systems level of service. • It also identifies three different levels: • “Problem Pertinent” - level 1 • “Extended” - level 2 • “Complete” - level 3

12. How Many Terms/Systems? When accumulating the total count of ROS body systems met, the total will include 1 for each body system that has one or more items identified. • If the accumulated total is equal to 1, level 1 is assigned • If the accumulated total is between 2 and 9, a level 2 is assigned. • If the accumulated total is greater than 9, a level 3 is assigned.

13. Level 1 – 1 Term from 1 System HPI Terms can go to the ROS but ROS Terms DO NOT carry over to the HPI unless it is a positive finding and the “flip term” option is turned on.

14. Level 2 – 1 Term From 2 to 9 Systems

15. Level 3 – 1 Term From More Than 9 Systems Most exams will not hit level 3 nor is it needed for getting high RVU’s

16. Physical Exam

17. How Much Should You Do? • Obviously there will be a lot of encounters (i.e. Established Patients) where little or no physical exam occurs • However when a physical exam is done or must be done (i.e. New Patients) be sure to get credit for what you do! • Things like “Vitals” “Orientation” “Gait” and “Appearance” should be automatic on almost any exam

18. How Many Terms Do I Need? • “Generally Speaking” at least 2 Descriptors in each System should be used • Sometimes a single Descriptor from 2 Separate Systems will give the same results • For example in the next slide you will see that “Gait and Stance” and “Orientation” are single Descriptors from different Systems but by choosing both Descriptors they combine to make the two normally needed from one System

19. Medcin vs. CMSNOTE: Occasionally objects in the Medcin tree will show up in different places in the CMS tree

20. There are four levels of Physical Exam “Problem Focused”, “Expanded Problem Focused”, “Detailed”, and “Comprehensive” . The higher the level the more it will influence the final E&M code. To know what scores click the Exam box in the Disposition Module.

21. The CMS TREE 1997 Edition The 12 “systems” listed in the box are part of the 1997 CMS guidelines which uses “Bullet Points” to determine the level of examination or service.

22. The level of service is graded by a combination of the number of Systems selected With the number Descriptors checked in each System.

23. Don’t Confuse Medcin with CMS The CMS tree counts the Bullet Points you have chosen from Medcin Medcin builds the S/O note

24. Level 3 – “Detailed” As you move from a basic to a more advanced exam your score will increase as long as you continue to use the correct combination of Systems and Descriptors. As you can see a level 3 exam is not hard to achieve if you know what to choose! In this example I have 8 common Systems and 18 Descriptors

25. Level 3 – “Detailed” Example Two However in this example I used only 6 common Systems. As a result I had to use 24 Descriptors to get the same results

26. Level 4 – “Comprehensive”

27. Coding and RVU’s

29. What Are They Worth in 2008? 2008 Medicare CF= $34.0682

34. E/M CALCULATOR

35. Here’s Something New • Notice a point goes in the ROS as well!

36. Usability Aim Form

37. THIS USABILITY AIM FORM CAN BE USED FOR ABOUT 85% OF ALL VISITS AS THE FIRST TEMPLATE

38. This template has been added to your clinic folder with A name that includes a “#” which, when added to your Favorites will move it to the top of your drop down list In the S/O module NOTE: THIS ENCOUNTER TEMPLATE HAS THE DOD AIM FORM ON IT AND WILL BE UPDATED AUTOMATICALLY. YOU WILL USE THIS TEMPLATE FOR S/O DOCUMENTATION ONLY AND THEN LOAD YOUR DEFAULT ENCOUNTER TEMPLATE OR DISEASE SPECIFIC TEMPLATE FOR THE A/P PORTION WITH DX, PROC CODES AND ORDERS

39. GO TO CLINIC FOLDER AND EXPAND NEW TEMPLATES SUBFOLDER AND THEN CLICK ONCE TO SELECT AND THEN ADD TO FAVS

42. Use the HPI/Screening Tab for Chief Complaint and past history, family history, and social history Addressing Tobacco and/or Alcohol here gives 1 credit point to Social History…

44. Coding rules are listed at the top. 1 for Problem Pertinent. 2 -9 ROS must be covered for a 99214 (Extended level ROS) from 2 or more different organ systems, etc. Must be clinically important to get credit!

45. USE THE ‘ALL NORMAL” BUTTONS TO QUICKLY DOCUMENT NORMAL ROS AND THEN CHANGE YOUR ABNORMAL FINDINGS. NOTE HOW YOU SHOULD FLIP + ROS TO HPI SO ALL YOUR + FINDINGS IN HPI

46. Use the quick normal findings button and Change from N to Y or N to A for abnormal And then describe using the free text box

48. Use New Templates • Excellent AIM Form Templates Exist • Alternate Input Method • Usability Aim for Primary Care and Pre/Post OP • Specialty Specific Templates also exist now • Searching for Templates • S/O Templates • Encounter Templates • List of Templates

50. Templates Resources List of Templates Power point and word documents on how to’s and FAQ SEE NEXT SLIDE