Proper documentation for Lab and Radiology Visits

1. Proper documentation for Lab and Radiology Visits How to complete a Lab or Radiology Visit Catherine Moore Phoenix Area CAC

2. Lab Only Visits • Setup prior to doing the Lab Only Visits: -Create a “Lab Only” clinic in the Scheduling Package Procedure: • Ask the patient if they are seeing a provider today. If they are not, continue. • Select the patient in EHR. • Locate the lab order on the Order Tab and note the provider and date the labs were ordered. You may need to double click on the Order for the details on when it was originally ordered. • Create a new visit by clicking on the New Visit tab in EHR and selecting “Lab Only” as the visit location.

3. Lab Only Visits • Select the ordering provider (provider who originally ordered the lab) as the primary provider for this Lab Only visit. • Under Historical Diagnosis, locate the diagnosis for the date when the orders were ordered. • Double click on the historical diagnosis. This will add it as today’s diagnosis. • Accession the test and perform. • Note: v 72.6 is no longer used to document a lab only visit, it is a redundant code. Only use the medical necessity code. • Note: it may be difficult for the lab personnel to determine which historical diagnosis is related to the test. Help is coming!

4. Lab Orders with v 1.1 • In EHR version 1.1, the ordering provider will enter the “Clinical Indication”. This can be used as the diagnosis for the Lab Only Visit.

5. Radiology Only Visits • Setup prior to doing the Radiology Only Visits: -Create a “Radiology Visit Only” clinic in the Scheduling Package with “Create a visit” set to yes - Create a “Radiology” ICD Picklist in the EHR Procedure: • Make an appointment for the patient for the exam • When the patient arrives for the exam, check them into the appointment • Select the patient in EHR. • Enter the radiology tech who will be performing the procedure as the primary provider

6. Radiology Only Visits • Locate the original imaging order on the order tab • Double click on the order to view the order details. Read the History and Reason for the exam. This will give you the information needed for the diagnosis. • On the POV, add a diagnosis and enter the History and Reason in the narrative box • If the patient’s diagnosis is known, use the picklist to add or add from the Historical Diagnosis list • DO NOT add a diagnosis that the patient does not already have • Note: v 72.5 is no longer used for Radiology visits, it is redundant. Use the medical necessity code

7. EHR Coding Queue • How do these visits look in the coding queue? PCC VISIT DISPLAY Mar 21, 2007 14:37:02 Page: 1 of 3 Patient Name: DEMO,CAROL Chart #: 140557 Date of Birth: FEB 22, 1991 Sex: F Visit IEN: 2107395 =============== VISIT FILE =============== VISIT/ADMIT DATE&TIME: MAR 20, 2007@15:41 DATE VISIT CREATED: MAR 20, 2007 TYPE: TRIBE-NON 638/NON-COMPACT PATIENT NAME: DEMO,CAROL LOC. OF ENCOUNTER: DEMO HOSPITAL SERVICE CATEGORY: AMBULATORY CLINIC: RADIOLOGY DEPENDENT ENTRY COUNT: 2 DATE LAST MODIFIED: MAR 20, 2007 WALK IN/APPT: APPOINTMENT HOSPITAL LOCATION: RADIOLOGY ONLY CREATED BY USER: MOORE,CATHERINE =============== PROVIDERs =============== PROVIDER: MOORE,CATHERINE AFF.DISC.CODE: 906064 PRIMARY/SECONDARY: PRIMARY =============== POVs =============== POV: .9999 ICD NARRATIVE: UNCODED DIAGNOSIS PROVIDER NARRATIVE: abdominal pain, not pregnant PRIMARY/SECONDARY: PRIMARY EVENT DATE AND TIME: MAR 20, 2007@15:43:33 ENCOUNTER PROVIDER: MOORE,CATHERINE