Patient Care Component (PCC) Data Entry & Coding Pat Gowan, MPA, RHIA National Medical Records Consultant Phoenix Area Office
PCC DE & Coding • PCC Overview • PCC Forms • PCC Data Entry • Health Summary • Coding • PCC Manuals • PCC Training Classes
PCC Overview • PCC provides for the collection, integration, and storage of a broad range of health data resulting from outpatient, inpatient, and field visits. • It is designed to support health care delivery, planning, management, and research. • It is a tool that assists in providing the type of care that addresses all of a patient's known health problems and preventive health needs. • It includes date, type, and location of visit; providers; measurements; diagnoses and procedures; health problems and treatment plans; personal and family history; reproductive factors; lab test results; and a variety of other health-related information.
PCC Forms • Ambulatory Encounter Record, IHS-803 • Emergency Visit Record, IHS-114 • Brief Visit Record, IHS-464 • Multi-Visit Encounter Record, IHS-372 • Group Preventive Services, IHS-367 • Adult History and Physical Examination Record, IHS-465
Preparing Forms for Data Entry • All forms must be screened for the following items prior to being entered: • Date, Time, Location (e.g., school) • Clinic • Primary provider • Purpose of Visit/diagnosis • Patient ID (name, health record number) • Signature of the primary care provider.
PCC Data Entry • The Data Entry Module facilitates entry of information about a patient from a variety of forms into the PCC. • The most commonly used form is the PCC Ambulatory Encounter Record, IHS-803. • A patient must be registered in Patient Registration before any data can be entered.
Data Entry • The following data items will be entered if recorded on the form: • Secondary Provider (s) • Measurements: Height, Weight, Blood Pressure, Head Circumference, and Vision • Lab Tests Ordered (only if Laboratory Module is not operational) • Procedures • Exams Performed • Immunizations • Skin Test Readings/Results • Problems and/or Notes • Cause and Place of Injury on First Visits • Reproductive Factors • Personal or Family History • History of Immunization, Skin Test Readings, and Procedures
PCC Menu • The data entry system consists of the following features: • On-line help screens • On-line help prompts • On-line entry to multiple PCC dictionaries (e.g., Visit, Provider, Purpose of Visit, Measurement, etc.) • On-line editing and visual verification of data entered • Computer-assisted (encoder) ICD-9 diagnostic and ICD-9 and CPT procedural coding.
DATA ENTRY MNEMONICS • MNEMONICS are used to facilitate entry of patient data into the PCC system. • A mnemonic consists of two to three characters, e.g., BP, WT that represent a specific data type and speed entry by reducing the number of key strokes necessary to enter patient health information. • A complete list of the mnemonics can be viewed by typing a <?> <RETURN>
Health Summary ********************************* ** PCC Data Entry Module ** ********************************* Version 2.0 DEMO WALK-IN CENTER ENT Enter/Modify/Append PCC Data ... DSP Display Data for a Specific Patient Visit PEF Print a PCC Visit in Encounter Form format UPD Update Patient Related/Non Visit Data ... DEU Data Entry Utilities ... GHS Generate Health Summary BHS Browse Health Summary DVB Display a PCC Visit w/limited Lab Display PDV Print a PCC Visit Display to a Printer
GHS Option • The GENERATE HEALTH SUMMARY (GHS) menu option is used to display a health summary for a specific patient on screen (View) or print. • The default health summary is the ADULT REGULAR. • Other standardized health summaries are: Pediatric, Dental, Immunization and Diabetes. • Health summaries may be customized.
COD Option LST List Visits for a Patient in a Date Range GHS Generate Health Summary AUN Find CHS Entry for a Given Authorization Number MRG Merge two Visits on Same Date DEL Delete All Data For A Visit SUP Data Entry SUPERVISORY Options and Utilities ... BHS Browse Health Summary COD Display IHS Coding Guidelines GC Pediatric Growth Charts MR2 Merge 2 Visits on 2 Different Dates
Coding Guidelines • OCD Option DISPLAY IHS CODING GUIDELINES allows the user to view the ICD-9 Coding Guidelines. • Official Coding Guidelines are also located in front of the ICD-9-CM Code book.
.9999 CODE • If the provider or the coder is unable to locate the appropriate code in the ICD-9 file or in the book, the code .9999 (UNCODED DIAGNOSIS) may be entered at the PURPOSE of VISIT prompt. • .9999 codes must be modified to an ICD-9 code
E-Codes (E800-E999) • External causes of Injury, Poisoning, and other Adverse Effects • E-codes should be used in addition to a code from the main chapters of the ICD-9 book indicating the nature of the condition
E-Code and Place of Occurrence Codes (E849) • MNEMONIC: PV Purpose of Visit ALLOWED VISIT RELATED ONLY • Enter PURPOSE of VISIT: 825.20 FX FOOT BONE NOS-CLOSED • ...OK? Yes// (Yes) • PROVIDER NARRATIVE: FRACTURE RIGHT FOOT • MODIFIER: • CAUSE (E-CODE): E880.1 E880.1 FALL ON OR FROM SIDEWALK CURB • ...OK? Yes// (Yes) • CAUSE (ECODE) #2: • CAUSE (ECODE) #3: • PLACE OF OCCURRENCE (E849.0-E849.9): E849.0 ACCIDENT IN HOME • ...OK? Yes// (Yes) • DATE OF INJURY: T-7 (JUN 06, 2008)
V Codes (V01-V86) • Supplementary classification of factors influencing health status and contact with health services • Person who is not currently sick visits the facility for immunizations • Person seeks treatment such as for dialysis, chemotherapy, cast change • Personal history of certain diseases, e.g., cancer • Telephone calls, Chart Reviews, Pharmacy refill plus the code for the reason/diagnosis
PCC Coding Queue • The Coding Queue captures all electronically created visits into a holding queue. • Prevents visits not reviewed by data entry/coder from passing directly to the RPMS TP Billing package or from exporting.
Provider and Clinic Codeshttp://www.ihs.gov/CIO/scb/index.cfm?module=W_CLINIC&option=list&num=82&newquery=1
PCC Manuals • Patient Care Component (PCC) Operator’s (User) Manual • Patient Care Component (PCC) Supervisor’s Manual • Patient Care Component (PCC) Mnemonics
Training Classes • PCC Data Entry I User Training • PCC Data Entry II Supervisor Training • PCC Outputs Reporting