Patient Treatment File PTF Basics: What You Don t Know Can Hurt You 146

1. Patient Treatment File (PTF) Basics: What You Don�t Know Can Hurt You (146) Phyllis J. Taylor, BS, RHIT, LPN Sheryll Hardesty, BS, CPC

2. 2 Patient Treatment File (PTF) (PTF) Patient Treatment File is an automated system for recording and tracking inpatient care received by all inpatients in a VA medical facility: (Acute, Community Living Center (CLC), Domiciliary, and Psychosocial Residential Rehabilitation Treatment Program) (PRRTP) Inpatient care in a non-VA medical facility at VA expense: Community Nursing Home (CNH),Non-VA hospitalization (i.e., fee medical and contract) PTF is the principle source of inpatient VHA workload data PTF has been around since the 1970�s Around 1986 (PTF) officially became an application in VistA which allowed data to be transmitted electronically to the National PTF Database which today is the National Patient Care Database (NPCD) PTF represents an abstract of a patient�s hospital episode of care Some History about PTF: The PTF represents an abstract of any and all inpatient episodes of care for hospital, long term care, and Non-VA hospital and Non-VA Nursing Home Care (CNH). It is an automated system for recording an tracking inpatient care in a VA medical facility and It is the principle source of inpatient VHA workload data. PTF officially became a package in VistA in 1986 which allowed the eletronic transmission of data to the National PTF Database which is now know as the National Patient Care Database. Some History about PTF: The PTF represents an abstract of any and all inpatient episodes of care for hospital, long term care, and Non-VA hospital and Non-VA Nursing Home Care (CNH). It is an automated system for recording an tracking inpatient care in a VA medical facility and It is the principle source of inpatient VHA workload data. PTF officially became a package in VistA in 1986 which allowed the eletronic transmission of data to the National PTF Database which is now know as the National Patient Care Database.

3. 3 PTF Overview The PTF provides a record of inpatient activity, diagnoses, procedures and surgeries performed from the time of admission to the time of discharge A PTF record is automatically created for a patient when an admission is entered into the system. The PTF consists of patient demographic data from the main PATIENT file and admission information. A non-VA care PTF is triggered from the Authorization function within the Fee application (i.e., Community Nursing Home and Non-VA hospitalizations) After patient discharge, the PTF record should be completed and closed. The data from the closed PTF must be transmitted to the Austin Information Technology Center (AITC), also known as the Austin Automation Center (AAC), which uses the data to compute the Diagnostic Related Groups (DRG�s) for resource allocation to the hospital. As I mentioned previously, the PTF provides a record of all inpatient activity during the patients stay from the time of of admission to the time of discharge. The PTF for hospital and long-term care stays are initiated by the Admission Discharge Transfer package and contains some information which is obtained from other files within other packages. Non-VA hospital and Non-VA Long Term care, which would be your community nursing home (CNH) PTFs, are initiated by the Fee Package at the time the authorization is approved. For these types of PTF abstracts, information that would be populated from other files/fields do not occur automatically, and must be manually populated by the responsible individual. There are many processes for obtaining this information and your facility should determine the most appropriate source to ensure accurate information is reported in the PTF abstract. Every inpatient stay in a VA facility or those for which the VA pays for the service, whether hospital or long-term care, will require a PTF record submission. In addition to this requirement, PTF records are submitted Quarterly for reporting Census. Census counts include those patients in a VA bed or NON-VA bed for which the VA pays for the care at midnight the last day of each quarter. As I mentioned previously, the PTF provides a record of all inpatient activity during the patients stay from the time of of admission to the time of discharge. The PTF for hospital and long-term care stays are initiated by the Admission Discharge Transfer package and contains some information which is obtained from other files within other packages. Non-VA hospital and Non-VA Long Term care, which would be your community nursing home (CNH) PTFs, are initiated by the Fee Package at the time the authorization is approved. For these types of PTF abstracts, information that would be populated from other files/fields do not occur automatically, and must be manually populated by the responsible individual. There are many processes for obtaining this information and your facility should determine the most appropriate source to ensure accurate information is reported in the PTF abstract. Every inpatient stay in a VA facility or those for which the VA pays for the service, whether hospital or long-term care, will require a PTF record submission. In addition to this requirement, PTF records are submitted Quarterly for reporting Census. Census counts include those patients in a VA bed or NON-VA bed for which the VA pays for the care at midnight the last day of each quarter.

4. 4 Closeout of Veterans Health Administration Corporate Patient Data Files (PTF) Monthly closeout: the 14th calendar day after the date of discharge. Yearly closeout: the 14th calendar day of October each fiscal year: (Note: Data that is not transmitted by the 14th calendar day after the event may not be included in VHA statistical calculations such as performance measures, including wait time for an appointment.) Exceptions to the rule: (Note: Community Nursing Home and Fee Basis patients, which can be submitted for the 2 prior fiscal years for authorized claims and 7 years for unauthorized claims.) Close out is the date for which each PTF record must be completed, closed, released, transmitted, and accepted to the National Patient Care Database. The deadline for all record types for inclusion is the 14th calendar day of each month and yearly on the 14th calendar day of October. Remember to keep in mind that data corrections received after the yearly October 14th calendar day deadline will be accepted in the National Patient Care Database (NPCD), but it will not be included in the corporate files for performance measures, planning and resource. Close out is the date for which each PTF record must be completed, closed, released, transmitted, and accepted to the National Patient Care Database. The deadline for all record types for inclusion is the 14th calendar day of each month and yearly on the 14th calendar day of October. Remember to keep in mind that data corrections received after the yearly October 14th calendar day deadline will be accepted in the National Patient Care Database (NPCD), but it will not be included in the corporate files for performance measures, planning and resource.

5. 5 Closeout Continued Timely receipt of quarterly closeout data to the Corporate Franchise Data Center (CFD) affects VHA in many ways: Through the Veterans Equitable Resource Allocation (VERA) process = dollars to your medical center Health care planning and statistical purposes Performance monitoring Annual reporting to Congress by the Secretary of Veterans Affairs Monthly closeouts reflect a snapshot for performance measures and other corporate reporting Corrections to data must be done in a timely manner: (Note: Data corrections received after the yearly October 14th calendar day deadline will be accepted in the National Patient Care Database (NPCD), but will not be included in the corporate files for performance measures, planning and resources.)

6. 6 PTF Basics The PTF abstract is comprised of multiple transactions Admission Transaction (101) Patient Movement Transaction (501) Physical Location Transaction (535) Procedure Transaction (Non OR) (601) Surgical Transaction (OR) (401) Principal Diagnosis/Discharge Transaction (701) Every episode of care requires for each patient, at a minimum, a 101, 501 and 701 Now I would like to go over the basics of the PTF: - Admission Transaction (101): This screen contains admission and discharge information for the episode of care and the basic patient demographic information. - Patient Movement Transaction (501): A Patient Movement Transaction (501) is completed for each transfer between bed sections in a VA health care facility ( including patients vacating a Domiciliary bed). A Patient Movement Transaction must be completed to report a change in specialty occurring during an episode of hospitalization and must include the related diagnostic codes. These screens are generated automatically by the application and there may be more than one during an inpatient stay. The movements themselves should not be edited by the site. For non-VA admissions, the (501) must be manually completed as it does not auto-populate as in the VA PTF. Patient movements of less than 24 hours (observation patients) and transfers that only involve a facility-treating-specialty change and not a PTF specialty change will not create a new patient movement in PTF. - Physical Location Transaction (535): Also referred to as the �MAS� screen, Is the PTF transaction that is completed in the background by the application each time a patient occupies a bed in a physical location/(bedsection) that is different from the treating specialty. Unlike the (501), it shows all bed movements involving the patient. (no user interaction is necessary in this screen.) - Procedure Transaction (601): Is a PTF transaction prepared to report non-OR (surgical procedures which do not take place in an operating room such as those conducted in an ambulatory surgery center, radiology, cath lab, endoscopy suite or at bedside) procedures performed during an episode of care. - Surgical Transaction (401): A PTF transaction completed to report surgical procedures performed in an operating room during an episode of care. Note: A 401 will not be prepared on Nursing Home, Dom or CNH patients. -Discharge Transaction (701): This PTF transaction is completed on every hospital inpatient, NHCU patient, Fee Basis inpatient, and Contract or CNH patient. The 701 is �created� when the patient has more than one diagnostic code to be entered, and contains the code for the principal diagnosis, which we should all know, is (the reason after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care). Note: A maximum of (13) thirteen codes can be entered on the 701 for the episode of care. The 701 and 501 may not match Note: For Long Term Hospitalizations, there is a maximum of 25 movements that can be transmitted to NPCD on the 501 Screen. Note: The 601 and 401 Screens are only utilized for those patients that may have had any procedures done during their inpatient stay. Keep in mind that there can only be 10 different procedure dates provided on the 601 Screen. NOTE: The PFT system accepts a maximum of thirty-two transactions per hospitalization. Now I would like to go over the basics of the PTF: - Admission Transaction (101): This screen contains admission and discharge information for the episode of care and the basic patient demographic information. - Patient Movement Transaction (501): A Patient Movement Transaction (501) is completed for each transfer between bed sections in a VA health care facility ( including patients vacating a Domiciliary bed). A Patient Movement Transaction must be completed to report a change in specialty occurring during an episode of hospitalization and must include the related diagnostic codes. These screens are generated automatically by the application and there may be more than one during an inpatient stay. The movements themselves should not be edited by the site. For non-VA admissions, the (501) must be manually completed as it does not auto-populate as in the VA PTF. Patient movements of less than 24 hours (observation patients) and transfers that only involve a facility-treating-specialty change and not a PTF specialty change will not create a new patient movement in PTF. - Physical Location Transaction (535): Also referred to as the �MAS� screen, Is the PTF transaction that is completed in the background by the application each time a patient occupies a bed in a physical location/(bedsection) that is different from the treating specialty. Unlike the (501), it shows all bed movements involving the patient. (no user interaction is necessary in this screen.) - Procedure Transaction (601): Is a PTF transaction prepared to report non-OR (surgical procedures which do not take place in an operating room such as those conducted in an ambulatory surgery center, radiology, cath lab, endoscopy suite or at bedside) procedures performed during an episode of care. - Surgical Transaction (401): A PTF transaction completed to report surgical procedures performed in an operating room during an episode of care. Note: A 401 will not be prepared on Nursing Home, Dom or CNH patients. -Discharge Transaction (701): This PTF transaction is completed on every hospital inpatient, NHCU patient, Fee Basis inpatient, and Contract or CNH patient. The 701 is �created� when the patient has more than one diagnostic code to be entered, and contains the code for the principal diagnosis, which we should all know, is (the reason after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care). Note: A maximum of (13) thirteen codes can be entered on the 701 for the episode of care. The 701 and 501 may not match Note: For Long Term Hospitalizations, there is a maximum of 25 movements that can be transmitted to NPCD on the 501 Screen. Note: The 601 and 401 Screens are only utilized for those patients that may have had any procedures done during their inpatient stay. Keep in mind that there can only be 10 different procedure dates provided on the 601 Screen. NOTE: The PFT system accepts a maximum of thirty-two transactions per hospitalization.

7. 7 PTF Basics PTF Keys DG PTFTRANS � Transmission Utilities Menu DG PTFSUP � PTF Utility Menu DG PTFREL � Open Closed PTF Records Overview highlights each option and if any required security key is necessary PTF Mail Groups PTT Mail Group PTF AUSTIN MESSAGES PTF Documentation for VistA on the VistA Documentation Library http://www.va.gov/vdl/VistA_Lib/Clinical/Admis_Disch_Transfer_(ADT)/ptf.pdf For those of you who do not know, this is a list of the PTF Security Keys given to designated individuals in the facility/department that will allow those individuals to make deletions or corrections to the information within PTF. DG PTFTRANS � Due to errors in reporting, there may be a need to delete an established master record or component segments of a record. A deletion action is used only when the record cannot be adjusted by using a replacement action. This option is only available to holders of this security key. This same security key will allow designated users to electronically transmit released PTF records to the Austin Automation Center as well. DG PTFSUP � DGPTFREL � PTF Mail Groups: To receive VistA email messages regarding PTF transmission (i.e. electronic EAL, transmission confirmation messages, etc.), ask your PAS or IRM to add you to these mail groups For those of you who do not know, this is a list of the PTF Security Keys given to designated individuals in the facility/department that will allow those individuals to make deletions or corrections to the information within PTF. DG PTFTRANS � Due to errors in reporting, there may be a need to delete an established master record or component segments of a record. A deletion action is used only when the record cannot be adjusted by using a replacement action. This option is only available to holders of this security key. This same security key will allow designated users to electronically transmit released PTF records to the Austin Automation Center as well. DG PTFSUP � DGPTFREL � PTF Mail Groups: To receive VistA email messages regarding PTF transmission (i.e. electronic EAL, transmission confirmation messages, etc.), ask your PAS or IRM to add you to these mail groups

8. 8 PTF Menus Census Menu� Checkoff PTF Message DRG Calculation Enter PTF Message Inquire PTF Message Load/Edit PTF Data National Patient Care Database� Open Closed PTF Record Open Rel/Trans PTF Record PTF Output Menu� PTF Transmission Quick Load/Edit PTF Data Release PTF Records for Transmission Set Up Non-VA PTF Record Update DRG Information Menu Utility Menu� The above menu is the PTF main menu which has an associated key. This means that in order to utilize this menu an individual user must possess the menu and the key. When you are given menu�s, you may or may not have all of these menu�s. In addition you may have additional options not listed here. The menus listed in this presentation are those indicated in the documentation library for the software. PTF Menu ... [DG PTF MENU] **> Locked with DGPTF Highlights of the PTF main menu: The focus for this presentation is on the use of particular options/menus from this listing. Other menus/options may not be mentioned but this does not diminish their importance. The ��.� behind a few of the listings indicates that there is a sub menu. Some of the Sub menus will be identified later in the presentation. Census Menu goes to a submenu containing options related to census CHECKOFF PTF MESSAGE is used to delete PTF messages from the PTF MESSAGE file. Before a PTF record can be closed, all PTF messages for the patient admission must be deleted. DRG CALCULATION computes the Diagnostic Related Group based on diagnoses and procedures/operations. ENTER PTF MESSAGE is used to enter and transmit PTF messages to the HIMS printer. PTF messages are stored in the PTF MESSAGE file. INQUIRE PTF MESSAGE is used to display PTF messages. LOAD/EDIT PTF DATA is used to enter/edit data to the open PTF record using screen entry format. National Patient Care Database goes to a submenu containing options related to transmission of information to the NPCD. OPEN CLOSED PTF RECORD is available to holders of the DG PTFREL security key to reopen a closed PTF record. OPEN RELEASED OR TRANSMITTED PTF RECORDS is used to reopen released or transmitted PTF records. Security key DG PTFTRANS is required to utilize this option. PTF Output menu goes to a submenu which provides users with several reporting capabilities. PTF TRANSMISSION is used to electronically transmit released PTF records to the Austin Automation Center. Security key DG PTFTRANS is required to utilize this option. QUICK LOAD/EDIT PTF DATA is used to enter/edit data to the open PTF record using list format ,rather than screen format, which allows for faster editing. RELEASE PTF RECORDS FOR TRANSMISSION is used to update the status of PTF records which have been closed by Health Information Management Section to RELEASED status. Security key DGPTFREL is required to utilize this option. SET UP NON-VA PTF RECORD creates PTF records for veterans being treated in a private facility at VA expense. UPDATE DRG INFORMATION MENU goes to a submenu UTILITY MENU goes to a submenu The above menu is the PTF main menu which has an associated key. This means that in order to utilize this menu an individual user must possess the menu and the key. When you are given menu�s, you may or may not have all of these menu�s. In addition you may have additional options not listed here. The menus listed in this presentation are those indicated in the documentation library for the software. PTF Menu ... [DG PTF MENU] **> Locked with DGPTF Highlights of the PTF main menu: The focus for this presentation is on the use of particular options/menus from this listing. Other menus/options may not be mentioned but this does not diminish their importance. The ��.� behind a few of the listings indicates that there is a sub menu. Some of the Sub menus will be identified later in the presentation. Census Menu goes to a submenu containing options related to census CHECKOFF PTF MESSAGE is used to delete PTF messages from the PTF MESSAGE file. Before a PTF record can be closed, all PTF messages for the patient admission must be deleted. DRG CALCULATION computes the Diagnostic Related Group based on diagnoses and procedures/operations. ENTER PTF MESSAGE is used to enter and transmit PTF messages to the HIMS printer. PTF messages are stored in the PTF MESSAGE file. INQUIRE PTF MESSAGE is used to display PTF messages. LOAD/EDIT PTF DATA is used to enter/edit data to the open PTF record using screen entry format. National Patient Care Database goes to a submenu containing options related to transmission of information to the NPCD. OPEN CLOSED PTF RECORD is available to holders of the DG PTFREL security key to reopen a closed PTF record. OPEN RELEASED OR TRANSMITTED PTF RECORDS is used to reopen released or transmitted PTF records. Security key DG PTFTRANS is required to utilize this option. PTF Output menu goes to a submenu which provides users with several reporting capabilities. PTF TRANSMISSION is used to electronically transmit released PTF records to the Austin Automation Center. Security key DG PTFTRANS is required to utilize this option. QUICK LOAD/EDIT PTF DATA is used to enter/edit data to the open PTF record using list format ,rather than screen format, which allows for faster editing. RELEASE PTF RECORDS FOR TRANSMISSION is used to update the status of PTF records which have been closed by Health Information Management Section to RELEASED status. Security key DGPTFREL is required to utilize this option. SET UP NON-VA PTF RECORD creates PTF records for veterans being treated in a private facility at VA expense. UPDATE DRG INFORMATION MENU goes to a submenu UTILITY MENU goes to a submenu

9. 9 QuadraMed Interface to PTF How does QuadraMed interface with PTF? QuadraMed is Interfaced with VistA and in order to access PTF in QuadraMed, you must log in to VistA. When opening the QuadraMed interface to PTF you should look for the icon that will provide you access to VIP Workplace Live at your facility. Your icon may look different from the person in VISN 7 or VISN 1 either way it will get you to this point where you will log in to VistA. Once you have selected the appropriate icon and click on it, a window will pop-up that looks like this � where you will then need to enter your VistA Access and Verify code. How does QuadraMed interface with PTF? QuadraMed is Interfaced with VistA and in order to access PTF in QuadraMed, you must log in to VistA. When opening the QuadraMed interface to PTF you should look for the icon that will provide you access to VIP Workplace Live at your facility. Your icon may look different from the person in VISN 7 or VISN 1 either way it will get you to this point where you will log in to VistA. Once you have selected the appropriate icon and click on it, a window will pop-up that looks like this � where you will then need to enter your VistA Access and Verify code.

10. 10 VIP Workplace Once you have gained access � (after entering your Access and Verify codes), your VIP Workplace screen will appear providing you with four options: You Can Click on the: Case Management tab � which will provide access to inpatient coding functions such as: Workload Reports and Selection of a patient�s record. You can right-click in the results area, and make sure that My Cases Only is deselected in order to see all of the records and not just the ones assigned to the logged in user. Click on the Retrieve Cases button at the top of the screen and coder has access to their assigned cases. Open Patient Chart tab and � select a patient Transmission Log tab � allows the coder to see what PTFs have been transmitted And the Bulletin Board tab � displays any patches that have been installed as well as the version that is currently running. Once you have gained access � (after entering your Access and Verify codes), your VIP Workplace screen will appear providing you with four options: You Can Click on the: Case Management tab � which will provide access to inpatient coding functions such as: Workload Reports and Selection of a patient�s record. You can right-click in the results area, and make sure that My Cases Only is deselected in order to see all of the records and not just the ones assigned to the logged in user. Click on the Retrieve Cases button at the top of the screen and coder has access to their assigned cases. Open Patient Chart tab and � select a patient Transmission Log tab � allows the coder to see what PTFs have been transmitted And the Bulletin Board tab � displays any patches that have been installed as well as the version that is currently running.

11. 11 VIP Workplace  Patient charts can be retrieved several ways: You can select the patient after retrieving the cases by clicking on the patient, then click on the Open Patient Chart tab by double-clicking. Another way is by: � Typing the first initial of the last name and the last four numbers of the SSN. Press the <Enter> key on the keyboard. � Type the full SSN. Press the <Enter> key on the keyboard. � Type the first three letters of the last name. Press the <Enter> key on the keyboard to bring up a list of patients. Select a patients name by double clicking on it and the 101 screen in the PTF Management tab will be launched. Note: If a Sensitive Patient is selected, it will be indicated on the right, above the patient�s name. Once the patient�s name is highlighted, information about that patient will appear on the right side of the screen: � Patient�s DOB (date of birth) � Patient�s SSN � Patient�s current location � Patient�s percentage of service connected condition � PTF Records (A record can be opened here by clicking on the + sign to expand the records and then double-clicking on the appropriate admission date. This too will bring the user to the 101 screen.) Note: If the patient information to the right is red, the patient is currently admitted. If the patient information is in blue, the patient has been discharged. Patient charts can be retrieved several ways: You can select the patient after retrieving the cases by clicking on the patient, then click on the Open Patient Chart tab by double-clicking. Another way is by: � Typing the first initial of the last name and the last four numbers of the SSN. Press the <Enter> key on the keyboard. � Type the full SSN. Press the <Enter> key on the keyboard. � Type the first three letters of the last name. Press the <Enter> key on the keyboard to bring up a list of patients. Select a patients name by double clicking on it and the 101 screen in the PTF Management tab will be launched. Note: If a Sensitive Patient is selected, it will be indicated on the right, above the patient�s name. Once the patient�s name is highlighted, information about that patient will appear on the right side of the screen: � Patient�s DOB (date of birth) � Patient�s SSN � Patient�s current location � Patient�s percentage of service connected condition � PTF Records (A record can be opened here by clicking on the + sign to expand the records and then double-clicking on the appropriate admission date. This too will bring the user to the 101 screen.) Note: If the patient information to the right is red, the patient is currently admitted. If the patient information is in blue, the patient has been discharged.

12. 12 VIP Workplace The Transmission Log displays a report that shows the number of records that are transmitted through VIP. The log can be printed using the Print Report option in the right-click menu. The Bulletin Board displays any patches that have been installed as well as the version that is currently running. The text displayed at the top of the Bulletin Board can be changed by IRM through the VIP WorkPlace.ini file. The Transmission Log displays a report that shows the number of records that are transmitted through VIP. The log can be printed using the Print Report option in the right-click menu. The Bulletin Board displays any patches that have been installed as well as the version that is currently running. The text displayed at the top of the Bulletin Board can be changed by IRM through the VIP WorkPlace.ini file.

13. 13 VIP Workplace Tabs As mentioned on Slide 10, once you select a patient from the list, the 101 Screen in the PTF Management Tab will be launched. The 101 Screen will also appear when the VIP Home icon is clicked. Similar to VistA CARS, VIP Workplace contains tabs to label various data screens and each tab represents a different section of the patient�s electronic medical record (excluding the PTF Management tab). The tab labels are: � PTF Management � Opened by default upon entering a patient�s record. � Clinical Coversheet � Discharge Summaries � Notes � Consults � Reports � Lab Reports � Imaging � Medications � Surgery As mentioned on Slide 10, once you select a patient from the list, the 101 Screen in the PTF Management Tab will be launched. The 101 Screen will also appear when the VIP Home icon is clicked. Similar to VistA CARS, VIP Workplace contains tabs to label various data screens and each tab represents a different section of the patient�s electronic medical record (excluding the PTF Management tab). The tab labels are: � PTF Management � Opened by default upon entering a patient�s record. � Clinical Coversheet � Discharge Summaries � Notes � Consults � Reports � Lab Reports � Imaging � Medications � Surgery

14. 14 Admission Transaction (101) The 101 screen hold the patient demographics and eligibility criteria. The information for the 101 Screen should pass over from the registration package with the exception of information in sections 5, 6, and 7. The user is responsible for entering this information and for verifying that all other data in the 101 segment is accurate. NOTE: It is important to remember that certain fields must be completed in order to close/release the record. Each section is labeled with a number to the left of the data items. In order to edit a section, the user must select the number at the prompt. The 101 screen hold the patient demographics and eligibility criteria. The information for the 101 Screen should pass over from the registration package with the exception of information in sections 5, 6, and 7. The user is responsible for entering this information and for verifying that all other data in the 101 segment is accurate. NOTE: It is important to remember that certain fields must be completed in order to close/release the record. Each section is labeled with a number to the left of the data items. In order to edit a section, the user must select the number at the prompt.

15. 15 The DRG Coding screen is divided into three sections. The PTF Management section lists all of the admissions for the selected patient. The Quantim Coding section displays codes retrieved using Quantim and the Quantim Coding button. The DRG Coding section contains the 401,501, 601, and 701 transaction data, which we will discuss later, along with the Technical and Quantim edits. To access Quantim Coding in order to retrieve codes to be imported to the appropriate PTF record segments, click on the Quantim Coding button that is at the bottom of the section. The DRG Coding screen is divided into three sections. The PTF Management section lists all of the admissions for the selected patient. The Quantim Coding section displays codes retrieved using Quantim and the Quantim Coding button. The DRG Coding section contains the 401,501, 601, and 701 transaction data, which we will discuss later, along with the Technical and Quantim edits. To access Quantim Coding in order to retrieve codes to be imported to the appropriate PTF record segments, click on the Quantim Coding button that is at the bottom of the section.

16. 16 Utilizing the Quantim Encoder The benefit of using the QuadraMed interface for PTF is the availability of the encoder. This is the encounter codelist. After clicking on the Quantim Coding button the Coder will utilize this screen to lookup a diagnosis or procedure/surgery. While we all know that code books are for researching codes, the Codelist is for recording the the results of the search. Think of the Codelist as a worksheet for coding a patient�s record. Coders can either type in the word or type in the actual code if it is known. When finished coding: Mark as Complete and click on the Save button. Supervisors and Users alike will need to make sure that the POA (Present on Admission) indicators for each diagnosis is entered on this screen. Choose from one of the following indicators: � Y � Present on Admission � N � Not Present on Admission � U � Unknown � W � Clinically Undetermined or � That the diagnosis is exempt from POA reporting The edits in Quantim Compliance will run against the codes given and will bring the user to the Quantim Compliance screen for further review if an edit is triggered. The user will review the Compliance Screen and have an opportunity then to make any changes. The benefit of using the QuadraMed interface for PTF is the availability of the encoder. This is the encounter codelist. After clicking on the Quantim Coding button the Coder will utilize this screen to lookup a diagnosis or procedure/surgery. While we all know that code books are for researching codes, the Codelist is for recording the the results of the search. Think of the Codelist as a worksheet for coding a patient�s record. Coders can either type in the word or type in the actual code if it is known. When finished coding: Mark as Complete and click on the Save button. Supervisors and Users alike will need to make sure that the POA (Present on Admission) indicators for each diagnosis is entered on this screen. Choose from one of the following indicators: � Y � Present on Admission � N � Not Present on Admission � U � Unknown � W � Clinically Undetermined or � That the diagnosis is exempt from POA reporting The edits in Quantim Compliance will run against the codes given and will bring the user to the Quantim Compliance screen for further review if an edit is triggered. The user will review the Compliance Screen and have an opportunity then to make any changes.

17. 17 Saving Codes to the (701)

18. 18 Adding a Surgical Episode (401)

19. 19 Adding a Non-OR Procedure (601)

20. 20 Completed 501 Once all movement information has been added/updated the user can move to the next segment.Once all movement information has been added/updated the user can move to the next segment.

21. 21 Updating Segments of the 501

22. 22 Adding Diagnosis to 701

23. 23 Populated (701)

24. 24 Close Record Once coding of the PTF record is complete, the PTF record can be closed by clicking on the Close Record button. Keep in mind that (The Close Patient Chart) option only closes the chart so that another patient chart can be opened). Notice the tabs across the bottom which allow you to close and release a PTF record in an open status, as well as the option to re-open a PTF record in a closed/released status. Once coding of the PTF record is complete, the PTF record can be closed by clicking on the Close Record button. Keep in mind that (The Close Patient Chart) option only closes the chart so that another patient chart can be opened). Notice the tabs across the bottom which allow you to close and release a PTF record in an open status, as well as the option to re-open a PTF record in a closed/released status.

25. 25 Close Record When the Close Record button is clicked, an edit check is performed and the results are displayed on the Close Record Status screen. The PTF Technical Edit Report (VistA Edit information) is displayed first, followed by the VERA Edit, Quantim Coding Edit, and Quantim Compliance Edit Reports. If action needs to be taken to clear the edits, click on the Cancel button to return to the record. If no action is required, and the record is ready to be closed perform the following steps: 1. Select a PTF Status option of Close Record or Close and Release Record. 2. Enter or update the case comment. 3. Select a VIP Action. 4. Click on the Update button. When the Close Record button is clicked, an edit check is performed and the results are displayed on the Close Record Status screen. The PTF Technical Edit Report (VistA Edit information) is displayed first, followed by the VERA Edit, Quantim Coding Edit, and Quantim Compliance Edit Reports. If action needs to be taken to clear the edits, click on the Cancel button to return to the record. If no action is required, and the record is ready to be closed perform the following steps: 1. Select a PTF Status option of Close Record or Close and Release Record. 2. Enter or update the case comment. 3. Select a VIP Action. 4. Click on the Update button.

26. 26 Closed Record Status Technical Edits Technical Edits appear in the DRG Coding screen below the 601 Data Segment and on the Close Record Status screen when the PTF record is being closed. These are the outstanding VistA edits Quantim VERA Edits VERA edits are built into the Quantim database and can be turned on/off in the Compliance ? Setup section. VERA edits will be displayed based upon the code set that the VA has to define each VERA class. Those same edits will be displayed in the VIP WorkPlace Close Record Status window when the user clicks on the Close Record button after saving the Quantim Coding Compliance sessions. They will also display in the DRG Coding screen if the user cancels the Close Record process Quantim Edits(QC) The edits that are displayed in this section originate from the last Quantim Coding session initiated by the user. These are informational only. The user could go back into Quantim Coding prior to the close/release of the record to resolve any edits, if necessary. Technical Edits Technical Edits appear in the DRG Coding screen below the 601 Data Segment and on the Close Record Status screen when the PTF record is being closed. These are the outstanding VistA edits Quantim VERA Edits VERA edits are built into the Quantim database and can be turned on/off in the Compliance ? Setup section. VERA edits will be displayed based upon the code set that the VA has to define each VERA class. Those same edits will be displayed in the VIP WorkPlace Close Record Status window when the user clicks on the Close Record button after saving the Quantim Coding Compliance sessions. They will also display in the DRG Coding screen if the user cancels the Close Record process Quantim Edits(QC) The edits that are displayed in this section originate from the last Quantim Coding session initiated by the user. These are informational only. The user could go back into Quantim Coding prior to the close/release of the record to resolve any edits, if necessary.

27. 27 Confirmation Close/Release Record A confirmation that the record has been closed will be displayed. A confirmation that the record has been closed will be displayed.

28. 28 QuadraMed Right Click Menu In the PTF Management tab while on the 101 screen, you can right � click to access menu options that are available for use in entering/editing data within a PTF record such as: Refresh Code List � which refreshes the codes listed on the DRG Screen Update Case Action To � which will reset the status of the record to Coded, Re-Coded, or Review Set up Non-VA PTF Record � which allows the user to create a Non-VA PTF Record (Fee Basis Record) Facility Search � allows the user to look-up the name and number of a VA facility Display Associated TIU Notes � Clicking on this displays the Discharge Summary for the selected admission Calculate DRG for PTF Record � This option calculates and displays the DRG for the selected record Coding Compliance � Select this option to perform one of two tasks: -- Send an e-mail to the provider or anyone in the VistA mail group or -- Access the claims tracking system Perform Edit Check on PTF Record � This option performs and displays the results of an audit of the selected PTF Record.In the PTF Management tab while on the 101 screen, you can right � click to access menu options that are available for use in entering/editing data within a PTF record such as: Refresh Code List � which refreshes the codes listed on the DRG Screen Update Case Action To � which will reset the status of the record to Coded, Re-Coded, or Review Set up Non-VA PTF Record � which allows the user to create a Non-VA PTF Record (Fee Basis Record) Facility Search � allows the user to look-up the name and number of a VA facility Display Associated TIU Notes � Clicking on this displays the Discharge Summary for the selected admission Calculate DRG for PTF Record � This option calculates and displays the DRG for the selected record Coding Compliance � Select this option to perform one of two tasks: -- Send an e-mail to the provider or anyone in the VistA mail group or -- Access the claims tracking system Perform Edit Check on PTF Record � This option performs and displays the results of an audit of the selected PTF Record.

29. 29 Quantim Coding References The use of the encoder allows the user to have access to eletronic resources such as CPT Guidelines, Coding Clinic, CPT Assistant, Stedmans Medical Dictionary, ICD-9 Guidelines, and much more. Under the Reference link at the top of the screen there is a wealth of valuable information available to assist the coder. This information is integrated into Quantim Coding and is available from the right-click menu, hyperlinks within the Code Books and often in the Coders Tool Box. These references are updated regularly. The use of the encoder allows the user to have access to eletronic resources such as CPT Guidelines, Coding Clinic, CPT Assistant, Stedmans Medical Dictionary, ICD-9 Guidelines, and much more. Under the Reference link at the top of the screen there is a wealth of valuable information available to assist the coder. This information is integrated into Quantim Coding and is available from the right-click menu, hyperlinks within the Code Books and often in the Coders Tool Box. These references are updated regularly.

30. 30 Coding Edits Coding edits which indicate a possible coding conflict/error are highlighted in yellow. Note: Addressing All Errors and Warnings from the coding screens will often save the user from going into Compliance. Complication and Co-morbidities are indicated by the ccCoding edits which indicate a possible coding conflict/error are highlighted in yellow. Note: Addressing All Errors and Warnings from the coding screens will often save the user from going into Compliance. Complication and Co-morbidities are indicated by the cc

31. 31 Display of Code Edits The edits that are displayed in this section originate from the last Quantim Compliance session that was initiated by the user. These are for informational purposes only. The user could go back to Quantim Compliance prior to the close/release of the record to resolve any Compliance edits, if necessary.The edits that are displayed in this section originate from the last Quantim Compliance session that was initiated by the user. These are for informational purposes only. The user could go back to Quantim Compliance prior to the close/release of the record to resolve any Compliance edits, if necessary.

32. 32 PTF Output Menu Option Admissions without an associated PTF record CDR Inquiry Comprehensive Report by Admission Diagnostic Code PTF Record Search DRG Information Report DRG Reports Menu� Listing of Records by Completion Status Means Test Indicator of �U� Report Open PTF Record Listing Patient Summary by Admission Pro Fee Coding Not Sent to PCE Productivity Report by Clerk Surgical Code PTF Record Search Transmitted Records List Unreleased PTF Record Output Inquire PTF Record Admissions without an Associated PTF Record (Option name: DG PTF NO Admission) Prints admission records from bed control that have no PTF record associated with them. This occurs either because the admission occurred in an earlier software version or the record was deleted. Admissions that have had the corresponding PTF record purged through the PTF Archive/Purge option will NOT appear on this listing. CDR Inquiry (Option name: DG PTF CDR INQUIRY) This option allows the user to view the CDR information related to a particular PTF record. The information displayed is the same data shown on the �CDR� screen of the �Load/Edit PTF Record� option. If the PTF record selected is not closed, then the PTF record is automatically updated using the latest specialty and ward movement information. Comprehensive Report by Admission (Option Name: DG PTF COMPREHENSIVE REPORT): This output contains 101, 401, 501, MAS and 701 Screen for printing. Diagnostic Code PTF Record Search (Option name: DG PTF ICD DIAGNOSTIC SEARCH) The report searches for specific diagnostic codes that were coded in the PTF records. DRG Information Report (Option name: DG PTF DRG INFORMATION OUTPUT) This option generates an output which shows the DRGs that the user selected for the diagnosis codes and which DRG the codes fall into along with the DXLS. DRG Reports Menu (Option name: DG PTF DRG REPORTS) This is the main menu option to call the DRG outputs: DRG Case Mix Summary ALOS Report for DRGs Batch Multiple DRG Reports DRG Frequency Report DRG Index Report Trim Point DRG Report Listing of Records by Completion Status (Option name: DG PTF CODING REPORT) Prints report of closed and released records with number of patient movements and number of surgical movements, along with when the record was closed and released and who closed/released the records. Means Test Indicator of �U� Report (Option name: DG PTF MEANS TEST OF �U�) This option generates the Means Test Indicator of �U� Report. This report lists PTF records, within a specified date range, for which the means test is not done or not completed. This report will be sent to you in a VISTA email message. Subj: MEANS TEST = 'U' REPORT STATISTICS [#40755869] 04/13/05@16:09 9 lines From: DG PTF MT=U STATS In 'IN' basket. Page 1 *New* ------------------------------------------------------------------------------- Date Range for Report 10/1/04 to 4/1/05 Report Started 4/1/05@16:09:16 Report Finished 4/1/05@16:09:22 Total Time for Report 0:00:06 PTF Records Scanned 4,646 PTF Records Reported 0 Patient Count 0 Open PTF Record Listing  (Option name: DG PTF OPEN RECORD LIST) List of Open PTF records by Discharge date contains the following information: PATIENT SSN ADM DATE D/C DATE DISCHARGE PTF # SPECIALTY (Of note: this listing does not include Non-VA PTF records in an open status). Patient Summary by Admission: (Option name: DG PTF SUMMARY DIAG/OP OUTPUT) This option generates a list of a patient's diagnosis codes, operation codes and procedure codes for an admission from the patient's PTF record. The output may be run to include up to 20 PTF records. VEHU, Patient One SSN: 000-001-2222 Admitted: 01/19/2005@14:33 Elig: NSC (VERIFIED) Discharge: 03/30/2005@11:51 Total LOS: 70 * Provider: VEHU, PROVIDER ONE PTF #: 197617 * indicates the most recent PROVIDER entered for this admission Movement Date: 03/30/2005@11:51 (Discharge 501) Losing Specialty: DOMICILIARY Discharge Move: (701/2/3 Diagnoses) DXLS: Diagnosis Codes, (cont.) Procedure Date: 01/19/2005@14:33 Pro Fees Not Sent to PCE option provides a report displaying the professional services (801s) provided to a patient that have not been transmitted to PCE for the selected date range. Productivity Report by Clerk: (Option name: DG PTF CODING CLERK REPORT) : Coding report by coding clerk PTF PRODUCTIVITY REPORT PATIENT SSN DATE # PM SURG CLOSED BY ON RELEASED BY ON CODING CLERK: VEHU, CODER ONE VEHU, PATIENT ONE 0000012222 3/11/06 1 0 VEHU, CODER ONE 3/11/06 VEHU, CODER ONE 3/11/06 Surgical Code PTF Record Search: (Option name: DG PTF ICD SURGICAL SEARCH) Searches for specific surgical codes in the PTF records. Transmitted Records List: (Option name: DG PTF TRANSMITTED RECORDS) Report prints in SSN order of all PTF records transmitted to Austin for a specified date range. This can then be compared to the EAL from Austin. Unreleased PTF Record Output: (Option name: DG PTF OPEN RECORD OUTPUT): -This option prints out the PTF records that have been closed out by the coding clerks but have not yet been released. Inquire PTF Record: (Option name: DG PTF COMPREHENSIVE INQUIRY) Comprehensive Report for a Single PTF Episode which contains the following: patient name; ssn; discharge date; admission date; ptf #; status Admissions without an Associated PTF Record (Option name: DG PTF NO Admission) Prints admission records from bed control that have no PTF record associated with them. This occurs either because the admission occurred in an earlier software version or the record was deleted. Admissions that have had the corresponding PTF record purged through the PTF Archive/Purge option will NOT appear on this listing. CDR Inquiry (Option name: DG PTF CDR INQUIRY) This option allows the user to view the CDR information related to a particular PTF record. The information displayed is the same data shown on the �CDR� screen of the �Load/Edit PTF Record� option. If the PTF record selected is not closed, then the PTF record is automatically updated using the latest specialty and ward movement information. Comprehensive Report by Admission (Option Name: DG PTF COMPREHENSIVE REPORT): This output contains 101, 401, 501, MAS and 701 Screen for printing. Diagnostic Code PTF Record Search (Option name: DG PTF ICD DIAGNOSTIC SEARCH) The report searches for specific diagnostic codes that were coded in the PTF records. DRG Information Report (Option name: DG PTF DRG INFORMATION OUTPUT) This option generates an output which shows the DRGs that the user selected for the diagnosis codes and which DRG the codes fall into along with the DXLS. DRG Reports Menu (Option name: DG PTF DRG REPORTS) This is the main menu option to call the DRG outputs: DRG Case Mix Summary ALOS Report for DRGs Batch Multiple DRG Reports DRG Frequency Report DRG Index Report Trim Point DRG Report Listing of Records by Completion Status (Option name: DG PTF CODING REPORT) Prints report of closed and released records with number of patient movements and number of surgical movements, along with when the record was closed and released and who closed/released the records. Means Test Indicator of �U� Report (Option name: DG PTF MEANS TEST OF �U�) This option generates the Means Test Indicator of �U� Report. This report lists PTF records, within a specified date range, for which the means test is not done or not completed. This report will be sent to you in a VISTA email message. Subj: MEANS TEST = 'U' REPORT STATISTICS [#40755869] 04/13/05@16:09 9 lines From: DG PTF MT=U STATS In 'IN' basket. Page 1 *New* ------------------------------------------------------------------------------- Date Range for Report 10/1/04 to 4/1/05 Report Started 4/1/05@16:09:16 Report Finished 4/1/05@16:09:22 Total Time for Report 0:00:06 PTF Records Scanned 4,646 PTF Records Reported 0 Patient Count 0 Open PTF Record Listing (Option name: DG PTF OPEN RECORD LIST) List of Open PTF records by Discharge date contains the following information: PATIENT SSN ADM DATE D/C DATE DISCHARGE PTF # SPECIALTY (Of note: this listing does not include Non-VA PTF records in an open status). Patient Summary by Admission: (Option name: DG PTF SUMMARY DIAG/OP OUTPUT) This option generates a list of a patient's diagnosis codes, operation codes and procedure codes for an admission from the patient's PTF record. The output may be run to include up to 20 PTF records. VEHU, Patient One SSN: 000-001-2222 Admitted: 01/19/2005@14:33 Elig: NSC (VERIFIED) Discharge: 03/30/2005@11:51 Total LOS: 70 * Provider: VEHU, PROVIDER ONE PTF #: 197617 * indicates the most recent PROVIDER entered for this admission Movement Date: 03/30/2005@11:51 (Discharge 501) Losing Specialty: DOMICILIARY Discharge Move: (701/2/3 Diagnoses) DXLS: Diagnosis Codes, (cont.) Procedure Date: 01/19/2005@14:33 Pro Fees Not Sent to PCE option provides a report displaying the professional services (801s) provided to a patient that have not been transmitted to PCE for the selected date range. Productivity Report by Clerk: (Option name: DG PTF CODING CLERK REPORT) : Coding report by coding clerk PTF PRODUCTIVITY REPORT PATIENT SSN DATE # PM SURG CLOSED BY ON RELEASED BY ON CODING CLERK: VEHU, CODER ONE VEHU, PATIENT ONE 0000012222 3/11/06 1 0 VEHU, CODER ONE 3/11/06 VEHU, CODER ONE 3/11/06 Surgical Code PTF Record Search: (Option name: DG PTF ICD SURGICAL SEARCH) Searches for specific surgical codes in the PTF records. Transmitted Records List: (Option name: DG PTF TRANSMITTED RECORDS) Report prints in SSN order of all PTF records transmitted to Austin for a specified date range. This can then be compared to the EAL from Austin. Unreleased PTF Record Output: (Option name: DG PTF OPEN RECORD OUTPUT): -This option prints out the PTF records that have been closed out by the coding clerks but have not yet been released. Inquire PTF Record: (Option name: DG PTF COMPREHENSIVE INQUIRY) Comprehensive Report for a Single PTF Episode which contains the following: patient name; ssn; discharge date; admission date; ptf #; status

33. 33 Utility Menu 099 Transmission Record Print-Out (RPO) Add/Edit Suffix Effective Date Delete PTF Record Establish PTF Record from Past Admission Print Special Transaction Request Log PTF Expanded Code Listing Purge Special Transaction Request Log Set Transmit Flag on Movements Validity Check of PTF Record Utility Menu: 099 Transmission (099 Transmission) - This option is used to delete the master record in Austin by transmitting a 099 record. Use of this option deletes the ENTIRE master record in Austin and changes the PTF status of the record at the local facility from Transmitted to Open. Only holders of the security key, DG PTFTRANS, may access this option. See Appendix B on the VDL website Record Printout (RPO) � This option is used to generate a record printout request of a PTF record to Austin DPC. Add/Edit Suffix Effective Date option is used to add/edit/delete the effective date multiple of the FACILITY SUFFIX file (#45.68). Delete PTF Record � This option is available to holders of the required security key to delete PTF records from the system. Only PTF records with an OPEN status can be deleted. If it becomes necessary to recreate a PTF record after it has been deleted, this may be accomplished thru the �Establish PTF Record from Past Admission� option. NOTE: If you enter a patient name and more than one open PTF record exists for that patient, the system will list admission dates of all open records and ask you to choose the correct record for deletion. Also note that if you need to delete a record that would also need to be deleted from the Master Record you must first use the option �099 Transmission�. Establish PTF Record from Past Admissions � This option is used to create a PTF record for an admission that does not have a corresponding PTF record. This may occur if the patient record was deleted. After selecting the patient name, the system will prompt for the admission date. The time of the admission must also be entered. To prevent duplicate PTF records for the same admission, an admission date for which a PTF record already exists will not be accepted at this prompt. Print Special Transaction Request Log � This option allows the user to generate a listing of special transaction requests. PTF Expanded Code Listing � This option will generate a listing of the expanded codes by category and ICD-9-CM codes. five categories - KIDNEY TRANSPLANT STATUS, LEGIONNAIRE'S DISEASE, PSYCHIATRY AXIS CLASSIFICATION, SUBSTANCE ABUSE, and SUICIDE INDICATOR. Purge Special Transaction Request Log � This option allows the user to purge special transaction requests. Set Transmit Flag on Movement � This option allows the supervisor to flag 501 or 535 movements for transmittal purposes. If a PTF records has more than twenty-five 501 or 535 movements (a limitation set by Austin DPC), the record cannot be closed or transmitted. Some of the movements must be flagged not to be transmitted. This is an Austin DPC limitation. The situation, where more than twenty-five 501's or 535's are present in a PTF record, is very rare. Validity Check of PTF Record � This option performs a validity check on all required fields of the PTF Record. Utility Menu: 099 Transmission (099 Transmission) - This option is used to delete the master record in Austin by transmitting a 099 record. Use of this option deletes the ENTIRE master record in Austin and changes the PTF status of the record at the local facility from Transmitted to Open. Only holders of the security key, DG PTFTRANS, may access this option. See Appendix B on the VDL website Record Printout (RPO) � This option is used to generate a record printout request of a PTF record to Austin DPC. Add/Edit Suffix Effective Date option is used to add/edit/delete the effective date multiple of the FACILITY SUFFIX file (#45.68). Delete PTF Record � This option is available to holders of the required security key to delete PTF records from the system. Only PTF records with an OPEN status can be deleted. If it becomes necessary to recreate a PTF record after it has been deleted, this may be accomplished thru the �Establish PTF Record from Past Admission� option. NOTE: If you enter a patient name and more than one open PTF record exists for that patient, the system will list admission dates of all open records and ask you to choose the correct record for deletion. Also note that if you need to delete a record that would also need to be deleted from the Master Record you must first use the option �099 Transmission�. Establish PTF Record from Past Admissions � This option is used to create a PTF record for an admission that does not have a corresponding PTF record. This may occur if the patient record was deleted. After selecting the patient name, the system will prompt for the admission date. The time of the admission must also be entered. To prevent duplicate PTF records for the same admission, an admission date for which a PTF record already exists will not be accepted at this prompt. Print Special Transaction Request Log � This option allows the user to generate a listing of special transaction requests. PTF Expanded Code Listing � This option will generate a listing of the expanded codes by category and ICD-9-CM codes. five categories - KIDNEY TRANSPLANT STATUS, LEGIONNAIRE'S DISEASE, PSYCHIATRY AXIS CLASSIFICATION, SUBSTANCE ABUSE, and SUICIDE INDICATOR. Purge Special Transaction Request Log � This option allows the user to purge special transaction requests. Set Transmit Flag on Movement � This option allows the supervisor to flag 501 or 535 movements for transmittal purposes. If a PTF records has more than twenty-five 501 or 535 movements (a limitation set by Austin DPC), the record cannot be closed or transmitted. Some of the movements must be flagged not to be transmitted. This is an Austin DPC limitation. The situation, where more than twenty-five 501's or 535's are present in a PTF record, is very rare. Validity Check of PTF Record � This option performs a validity check on all required fields of the PTF Record.

34. 34 099 Transmission Why you should use this option When you should use this option Open a released or transmitted PTF vs. 099 PTF Transmission It is important to note that if you are making changes to XXXXXXXX you should use this option to submit a 099 transmission to the NPCD instead of using the option �open a released/transmitted PTF�. This option sends a transmission to the NPCD indicating that you are making a change to a key element the change will need to be made at the site level and the record previously transmitted to NPCD is no longer correct. This option will allow the user to basically tell the NPCD that the record is being altered and will be resubmitted. Not doing this step could cause problems with variance in workload and statistical information gathered from data submitted on the PTF to NPCD, e.g. LOS could be different, number of discharges could be different at the site level than showing on PTf 419 reports and/or KLF workload statistics. Once a PTF record has been transmitted electroncially to the NPCD t is possible to open a transmitted record through the option �open a released or transmitted PTF�, it is preferable to use the 099 Transmission option to accomplish this. The use of the 099 option deletes the master record in Austin while use of this option does not. It is important to note that if you are making changes to XXXXXXXX you should use this option to submit a 099 transmission to the NPCD instead of using the option �open a released/transmitted PTF�. This option sends a transmission to the NPCD indicating that you are making a change to a key element the change will need to be made at the site level and the record previously transmitted to NPCD is no longer correct. This option will allow the user to basically tell the NPCD that the record is being altered and will be resubmitted. Not doing this step could cause problems with variance in workload and statistical information gathered from data submitted on the PTF to NPCD, e.g. LOS could be different, number of discharges could be different at the site level than showing on PTf 419 reports and/or KLF workload statistics. Once a PTF record has been transmitted electroncially to the NPCD t is possible to open a transmitted record through the option �open a released or transmitted PTF�, it is preferable to use the 099 Transmission option to accomplish this. The use of the 099 option deletes the master record in Austin while use of this option does not.

35. 35 Census A census PTF abstract is required for all bed occupants as of 11:59 p.m. on March 31, June 30, September 30, and December 31. A census abstract is automatically created at 11:59 p.m. on the census date, Community Nursing Home patients for which VA pays for service are the census process. All diagnoses and procedures must be included in the census PTF abstract as of the census day. See the VistA documentation manual at: http://www.va.gov/vdl/VistA_Lib/Clinical/Admis_Disch_Transfer_ADT)/ptf.pdf for additional information on the parameters and on how this occurs. It is important to note there is NO requirement to submit a census record for NON-VA Hospital Stays (contract/unauthorized/or mill bill acute hospital stay). It is not necessary for providers to complete VA Form 10-7976D, Medical Staff Census Worksheet. It is appropriate for the coder to extract the information from CPRS to complete the census PTF. When completing the Census Transaction Screens, the screens will look the same as when completing a routine PTF Admission screen. For the 701/702 census screen, a discharge date is not required. The 701/702 census screen is also where the census number can be located after the census record is closed. This number will change if you have to reopen the record for any reason. PTF abstracts on census patients discharged before census closeout should not be released for transmission until census closeout is completed to prevent the generation of duplicate record errors in Austin. NON-VA Census Patch DG*5.3*643 was released to the field on 05/04/05 This patch, DG*5.3*643, will allow for non-VA hospital and community nursing home data to be included in the census report that is transmitted to AAC. The non-VA hospital and community nursing home data will be included in the census, but state home facility and 1-day stay dialysis patient data will continue to be excluded. Purpose: The Patch created a Census Record for all patients with an open record on the designated date. This includes any Fee PTF Record such as Civil Hospital or Community Nursing Home (CNH). Only community nursing home patients will be included in the NON-VA census reporting process. Both NON-VA civil hospital and CNH patients have a record in PTF and will show up on the census report included in the patch. Sites may find that a NON-VA census record were created, as part of the normal census workfile, for a patient that has been identified as discharged prior to the Census period ending. If this is found sites should enter the discharge date in the NON-VA PTF record (not the census record) then run the Regenerate Census Workfile [DGPT CENSUS REGEN WORKFILE] option. This will remove the NON-VA Census record from the census status report.It is important to note there is NO requirement to submit a census record for NON-VA Hospital Stays (contract/unauthorized/or mill bill acute hospital stay). It is not necessary for providers to complete VA Form 10-7976D, Medical Staff Census Worksheet. It is appropriate for the coder to extract the information from CPRS to complete the census PTF. When completing the Census Transaction Screens, the screens will look the same as when completing a routine PTF Admission screen. For the 701/702 census screen, a discharge date is not required. The 701/702 census screen is also where the census number can be located after the census record is closed. This number will change if you have to reopen the record for any reason. PTF abstracts on census patients discharged before census closeout should not be released for transmission until census closeout is completed to prevent the generation of duplicate record errors in Austin. NON-VA Census Patch DG*5.3*643 was released to the field on 05/04/05 This patch, DG*5.3*643, will allow for non-VA hospital and community nursing home data to be included in the census report that is transmitted to AAC. The non-VA hospital and community nursing home data will be included in the census, but state home facility and 1-day stay dialysis patient data will continue to be excluded. Purpose: The Patch created a Census Record for all patients with an open record on the designated date. This includes any Fee PTF Record such as Civil Hospital or Community Nursing Home (CNH). Only community nursing home patients will be included in the NON-VA census reporting process. Both NON-VA civil hospital and CNH patients have a record in PTF and will show up on the census report included in the patch. Sites may find that a NON-VA census record were created, as part of the normal census workfile, for a patient that has been identified as discharged prior to the Census period ending. If this is found sites should enter the discharge date in the NON-VA PTF record (not the census record) then run the Regenerate Census Workfile [DGPT CENSUS REGEN WORKFILE] option. This will remove the NON-VA Census record from the census status report.

36. 36 Census Menu Load/Edit PTF Data Close Open Census Record Census Status Report Inquire Census Record Other Census Outputs Comprehensive Census Report Productivity Report by Clerk (Census Only) Records By Completion Status (Census Only) Transmitted Census Records List Unreleased Census Records Report Release Closed Census Records Transmit Census Records Open Closed Census Records Open Released or Transmitted Census Records 099 Transmission for Census Record Supervisor Menu Display Census Date Parameters Regenerate Census Workfile Fee Basis Census Status Report The Load/Edit PTF Data option is used to enter, edit, and view data contained in the PTF for a patient's period of hospitalization and to close and release these records for transmission. The Load/Edit PTF Data option under the Census Menu is intended for census purposes. The Close Open Census Record option provides you with a quick, easy means of closing PTF records for census purposes. A Census Status Report provides the names of the patients for which a census record must be completed. The Census Status Report allows you to print a report of all active admissions as of a specified census date. The first time the Census Status Report is run for a particular census date, a Census Work File is created for that date. The Inquire Census Record option is used to view the information contained in one or several patients' census record(s). The Comprehensive Census Report option provides a way to view the information contained in the census records in the PTF screen format. The Release Closed Census Records option allows you to release closed census records for later transmission. Once the record has been released, it is ready for transmission to the Austin Automation Center in Austin, TX through the Transmit Census Records option. The Transmit Census Records option is used to electronically transmit released census records to the Austin Automation Center in Austin, TX. The records are selected for transmittal by release date. The user may choose a single date or a range of dates. Only holders of the security key DG PTFTRANS may access this option. The Open Closed Census Records option is used to reactivate census records that have been closed but not released or transmitted. The OPEN RELEASED OR TRANSMITTED CENSUS RECORD is used to reopen released (record has been closed and is awaiting transmission) or transmitted (record has been electronically transmitted to Austin, TX) census records for the purpose of changing or correcting the record. Changes cannot be made until the record is reopened. When a record is reopened, the corresponding census entries in the PTF CLOSE OUT file and PTF RELEASE file are deleted. Also, the census record is deleted, and the census status is returned to OPEN. Supervisor menu: -The Display Census Date parameters allows the supervisor to view census date and parameters. -The Regenerate Census Workfile option allows the supervisor to regenerate the census workfile entries for a particular census date. The Fee Basis Census Status Report option is used to generate the PTF CensusStatus Report for census records with a type of FEE BASIS.The Load/Edit PTF Data option is used to enter, edit, and view data contained in the PTF for a patient's period of hospitalization and to close and release these records for transmission. The Load/Edit PTF Data option under the Census Menu is intended for census purposes. The Close Open Census Record option provides you with a quick, easy means of closing PTF records for census purposes. A Census Status Report provides the names of the patients for which a census record must be completed. The Census Status Report allows you to print a report of all active admissions as of a specified census date. The first time the Census Status Report is run for a particular census date, a Census Work File is created for that date. The Inquire Census Record option is used to view the information contained in one or several patients' census record(s). The Comprehensive Census Report option provides a way to view the information contained in the census records in the PTF screen format. The Release Closed Census Records option allows you to release closed census records for later transmission. Once the record has been released, it is ready for transmission to the Austin Automation Center in Austin, TX through the Transmit Census Records option. The Transmit Census Records option is used to electronically transmit released census records to the Austin Automation Center in Austin, TX. The records are selected for transmittal by release date. The user may choose a single date or a range of dates. Only holders of the security key DG PTFTRANS may access this option. The Open Closed Census Records option is used to reactivate census records that have been closed but not released or transmitted. The OPEN RELEASED OR TRANSMITTED CENSUS RECORD is used to reopen released (record has been closed and is awaiting transmission) or transmitted (record has been electronically transmitted to Austin, TX) census records for the purpose of changing or correcting the record. Changes cannot be made until the record is reopened. When a record is reopened, the corresponding census entries in the PTF CLOSE OUT file and PTF RELEASE file are deleted. Also, the census record is deleted, and the census status is returned to OPEN. Supervisor menu: -The Display Census Date parameters allows the supervisor to view census date and parameters. -The Regenerate Census Workfile option allows the supervisor to regenerate the census workfile entries for a particular census date. The Fee Basis Census Status Report option is used to generate the PTF CensusStatus Report for census records with a type of FEE BASIS.

37. 37 NON-VA PTF Records The NON-VA PTF record content appears to the user the same as regular PTF record with only a few exceptions. Notice the identification next to item 3 in the screen shot above �Fee Basis� Some of the other exceptions identified involve the information in specific segments that is usually populated from other packages On NON-VA PTF Records, 101 Screen the registration information does not pass over from registration, therefore the HIM staff will need to obtain all of the applicable information from the area responsible for maintaining this information (some facilities it may be Fee staff, Social Workers.) A listing of all CNH and Civil Admissions/Discharges, because they are authorized, can be obtained from the option: Activity Report for CNH' Option name: FBCNH ACTIVITY REPORT: This option prompts the user for input of a date range. The output includes all activity (admissions transfers and discharges) that fall within the date range.The NON-VA PTF record content appears to the user the same as regular PTF record with only a few exceptions. Notice the identification next to item 3 in the screen shot above �Fee Basis� Some of the other exceptions identified involve the information in specific segments that is usually populated from other packages On NON-VA PTF Records, 101 Screen the registration information does not pass over from registration, therefore the HIM staff will need to obtain all of the applicable information from the area responsible for maintaining this information (some facilities it may be Fee staff, Social Workers.) A listing of all CNH and Civil Admissions/Discharges, because they are authorized, can be obtained from the option: Activity Report for CNH' Option name: FBCNH ACTIVITY REPORT: This option prompts the user for input of a date range. The output includes all activity (admissions transfers and discharges) that fall within the date range.

38. 38 NON-VA MOVEMENT SEGMENT (501) All of the information that is normally passed over from another package will not be completed on a NON-VA PTF, the user will need to complete all sections for the 501. All of the information that is normally passed over from another package will not be completed on a NON-VA PTF, the user will need to complete all sections for the 501.

39. 39 Adding A Movement The user will need to ensure they have entered the leave days and pass days which may be zero. No entry may result in an error and non-acceptance by the AAC into the Master File. The user will need to ensure they have entered the leave days and pass days which may be zero. No entry may result in an error and non-acceptance by the AAC into the Master File.

40. 40 Validation of Receipt by Austin Information Technology Center (AITC) Why is it important? What do I do when discrepancies are found? Error Analysis Listing (EAL) PTF 419 WHY?: It is important to validate the PTF 419 report to ensure acceptance of inpatient workload at the AAC. This workload is used for a variety of planning purposes (budgetary, performance measures, etc.) and it is essential you stay on top of validating this report so it's not such a cumbersome project as you near the end of the fiscal year and to make sure you do not lose workload. Monthly validation is recommended. It is also important to do in a timely manner in order to resolve any missing workload nearer to the time of occurrence. PTF 419 Report Validation 4 Sections: Hospital (506); NHCU (506 9AA); CNHC (506 CNH); Fee Basis (506 DS) Each entry is listed in this order by Discharge date then SSN How?: Run Discharge list by Date/SSN/or G&L or whatever report your facility is using. You will receive a 419 report each week or you may access the report from the Austin web site if you have appropriate access. The report on the website however does not give you totals. Total number of discharges should be received from your statistical clerk or whoever is responsible for compiling this data. If you find one on the discharge list but not on the 419, run a list of records transmitted by using the option �Transmitted Records List�. This list is in SSN order. Check the date of your 419. If the date the record was transmitted is after the date of the 419 report you can either wait until the next 419 to see if this record is on it or access Austin for the latest 419. Another helpful tool is the option �Listing of Records by Completion Status�. You can run this to report for records that were closed and not released and records that have been released. Again, check the dates to see if the date the record was closed or released to see if it falls within the date of the 419 report. Both lists will contain the name of the MRT who coded the PTF. If record was closed and not released, you should contact the MRT who coded the PTF for a reason why it was not released for transmission. If you still cannot find the reason, open the PTF record up again and close, release and retransmit. If you find a name on the 419 that is not on your source document, run the document again. The patient may have been discharged after you ran the list or a correction has been made to the statistics since you ran your list. Sometimes discharges are not put in the system as quick as they should be. If it is not on the discharge list, take appropriate action. Error Analysis Listing (EAL) The Austin Automation Center generates an Error Analysis Listing (EAL) electronically and via postal mail weekly to each facility, which includes all PTF transmissions for the previous week. This listing summarizes all of the data transmitted and accepted in to the master PTF and lists data which was rejected (i.e. �kicked out�) with the errors indicated by error codes. A listing of error codes may be found at ????(need to get from John) These errors MUST be corrected and re-transmitted to Austin to be included in the Master PTF which is the source for inpatient workload. WHY?: It is important to validate the PTF 419 report to ensure acceptance of inpatient workload at the AAC. This workload is used for a variety of planning purposes (budgetary, performance measures, etc.) and it is essential you stay on top of validating this report so it's not such a cumbersome project as you near the end of the fiscal year and to make sure you do not lose workload. Monthly validation is recommended. It is also important to do in a timely manner in order to resolve any missing workload nearer to the time of occurrence. PTF 419 Report Validation 4 Sections: Hospital (506); NHCU (506 9AA); CNHC (506 CNH); Fee Basis (506 DS) Each entry is listed in this order by Discharge date then SSN How?: Run Discharge list by Date/SSN/or G&L or whatever report your facility is using. You will receive a 419 report each week or you may access the report from the Austin web site if you have appropriate access. The report on the website however does not give you totals. Total number of discharges should be received from your statistical clerk or whoever is responsible for compiling this data. If you find one on the discharge list but not on the 419, run a list of records transmitted by using the option �Transmitted Records List�. This list is in SSN order. Check the date of your 419. If the date the record was transmitted is after the date of the 419 report you can either wait until the next 419 to see if this record is on it or access Austin for the latest 419. Another helpful tool is the option �Listing of Records by Completion Status�. You can run this to report for records that were closed and not released and records that have been released. Again, check the dates to see if the date the record was closed or released to see if it falls within the date of the 419 report. Both lists will contain the name of the MRT who coded the PTF. If record was closed and not released, you should contact the MRT who coded the PTF for a reason why it was not released for transmission. If you still cannot find the reason, open the PTF record up again and close, release and retransmit. If you find a name on the 419 that is not on your source document, run the document again. The patient may have been discharged after you ran the list or a correction has been made to the statistics since you ran your list. Sometimes discharges are not put in the system as quick as they should be. If it is not on the discharge list, take appropriate action. Error Analysis Listing (EAL) The Austin Automation Center generates an Error Analysis Listing (EAL) electronically and via postal mail weekly to each facility, which includes all PTF transmissions for the previous week. This listing summarizes all of the data transmitted and accepted in to the master PTF and lists data which was rejected (i.e. �kicked out�) with the errors indicated by error codes. A listing of error codes may be found at ????(need to get from John) These errors MUST be corrected and re-transmitted to Austin to be included in the Master PTF which is the source for inpatient workload.

41. 41 Electronic Access to PTF 419 Report Web site is http://austin.aac.va.gov A user must first have access to the Austin RSD (Roger�s Software Development) web portal. Please complete form VA-9957 and work with your Information Security Officer (ISO) to request access. If new user, need to establish an Austin User ID When completing the form, request Austin Functional Task Code 110EE02

42. 42 Electronic Access to PTF 419 Report

43. 43 Electronic Access to PTF 419 Report DISPOSITIONS IN MASTER FILE RCS 10-0042 OCTOBER 01, 2003 THRU June 22, 2010 � 557������������������� Dublin, GA DISP-DATE/TIME SSN PATIENT'S NAME INIT ADM-DATE/TIME LOS DRG STATUS OF DATA Once you gain access to Austin�s system and you run the report, this will be what you will end up with minus the patients names of course. You will need to validate the report you have from your facility against the report that you run from Austin and make sure that the necessary corrections are made.Once you gain access to Austin�s system and you run the report, this will be what you will end up with minus the patients names of course. You will need to validate the report you have from your facility against the report that you run from Austin and make sure that the necessary corrections are made.

44. 44 Other PTF information/Updates Psychiatric Residential Rehabilitation Treatment Program (PRRTP) represents a bed level of care within the psychiatric continuum. Regardless of their location, PRRTP beds are counted as VA beds represented by a suffix designation with several different treating specialties to differentiate the specific program designation. The appropriate suffix may be located in: Patient Treatment File (PTF) Coding Instructions � VHA Handbook 1907.04 https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1650

45. 45 References VistA Documentation Library: http://www.va.gov/vdl/ From the Clinical section, Select Admission/Discharge/Transfer (ADT), then click on PTF PTF Training Guide located on the HIM website PTF Error Code Guide located on the HIM website Applicable Directives and Handbooks: Closeout Of Veterans Health Administration Corporate Patient Data Files - VHA DIRECTIVE 2007-030 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=279 Recording Observation Patients - VHA DIRECTIVE 2009-064 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=314 Patient Treatment File (PTF) Coding Instructions � VHA Handbook 1907.04 https://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1650

46. 46 SPECIAL THANKS

47. 47 Contact Information Sheryll Hardesty, BS, CPCChief, HIM, Erie, PA 814 860-2534 sheryll.hardesty@va.gov  Phyllis J. Taylor, BS, RHIT, LPNTCF HIM InternDublin, GA/Mid-South Consolidated Patient Accounts Center 615-225-3555 phyllis.taylor3@va.gov 

48. 48 QUESTIONS ?????