Nuance® Clintegrity™ Coding/Abstracting Coding/Abstracting User Guide

18.3 Release Client Support

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Copyright Statement © 2018 Nuance Communications, Inc. All rights reserved. Nuance, the Nuance logo, and Clintegrity are trademarks and/or registered trademarks of Nuance Communications, Inc., and/or its subsidiaries in the United States and/or other countries. All other trademarks are properties of their respective owners. Table of Contents Clintegrity Coding/Abstracting User Guide Table of Contents

18.3 Release

What’s New ...... xix

Chapter 1  About Clintegrity Coding and Abstracting Features and Benefits ...... 1 Advantages of Coding ...... 2 Components of Coding...... 3 Essentials of Coding...... 3 About the Coding and Abstracting Labels...... 4

Chapter 2  Getting Started Enable Clintegrity Keystrokes in Flat Panel Monitors ...... 5 Configuring Your Browser...... 6 How to … Set Standard Browser Settings ...... 6 Configure Security Settings ...... 7 Set Print Page Options ...... 11 Set Recommended Options ...... 11 Set Custom Links ...... 13 Signing In ...... 14 How to … Start the Clintegrity Application ...... 14 Standard Sign In...... 15 First Time Sign In ...... 15 Rules for Creating Passwords ...... 16 Changing the user password from the Home Page ...... 16 Password Settings ...... 17 Get Help Signing In ...... 18

i Clintegrity Coding/Abstracting User Guide

Configuring Users...... 19 View Encounters Screen ...... 19 How to … Access Coding ...... 20 Overview of Coding Screen ...... 20 Patient Information Banner ...... 21 How to … Add or Change Patient Information...... 21 Codes Panel...... 24 Diagnosis and Procedure Grids ...... 24 Multi-Panel View (Codebook and Code Grids) ...... 24 Show/Hide Code Grids ...... 26 How to … Code Grid in expanded view...... 28 Code Icons and Text in Code Grid ...... 38 Code Packages...... 39 Code Connections...... 40 Code Edits...... 40

Chapter 3  Coding User Interface Navigating With Icons...... 41 Clintegrity Icons...... 41 Coding - Specific Icons ...... 43 Using Online Help ...... 45 How to … Access Online Help...... 45 Navigate in Online Help ...... 46 Search in Online Help ...... 46 Exit Online Help ...... 46

Chapter 4  Coding Setup Setting Coding Preferences...... 47 How to … Set Up User Preferences ...... 47 Set Up Facility Preferences...... 53 Determining Shuffle Settings...... 63 ii Table of Contents

Set Abstracting Screen Order...... 68 Set Up Global Preferences...... 69 Importing and Exporting Information...... 70 How to … Import Coding System Information ...... 70 Export Coding System Information...... 71 Adding Coding Variables...... 72 How to … Create or Change Synonyms ...... 73 View Synonyms ...... 75 Create or Change Smartips ...... 77 View Smartips...... 79 Create or Change Code Packages...... 81 Create or Change Alternate Descriptions...... 83 Setting Up Custom Statuses ...... 85 How to … Create a Custom Status ...... 85 About Required Fields and Read-Only Fields ...... 87 How to … Set Up Required and Read-Only Fields ...... 88 Setting Compliance Rules ...... 89 How to … Configure Compliance IP Selection Rules ...... 89 Configure Compliance IP Selection Rules ICD-10 ...... 93 Configure Compliance OP Selection Rules ...... 96 Configure Compliance OP Selection Rules ICD-10 ...... 99 About Rule Settings ...... 101 How to … Copy Coding Configuration to Multiple Facilities Settings ...... 102 Configure IP Rules Settings ...... 103 Configure OP Rules Settings ...... 106 Configure IP Rule Settings ICD-10...... 110 Configure OP Rules Settings ICD-10 ...... 116 Configure Physician Rules Settings ...... 120 Configure Physician Rules Settings ICD-10 ...... 123 About File Layouts ...... 126 How to … Create File Layouts ...... 126 About Custom References ...... 129 How to … Create Custom References ...... 129 Import Custom References...... 131

iii Clintegrity Coding/Abstracting User Guide

About the Batch DRG Grouper ...... 131 About the Batch Outpatient Grouper ...... 131 Batch Import Scheduler ...... 132 How to … Schedule Batch Import ...... 132 Batch Export Scheduler ...... 134 How to … Schedule a Batch Export...... 134

Chapter 5  Patients Overview of Patient Information ...... 139 Imported Data ...... 140 Data Collected...... 140 View Patient Page ...... 141 How to … Look Up a Patient ...... 141 Patient Info Banner ...... 143 How to … Add or Change Patient Information...... 143 About Merging Patient Records ...... 145 How to … Merge Patient Records ...... 147 Merging Encounters using HL7 Messages ...... 149 Expected Results by Module...... 150 Multiple Merges...... 152 Unmerge MRNs ...... 153 Unmerging Encounters using HL7 Messages...... 154 Patient Encounter Volumes ...... 155 How to … Add a New Volume ...... 155 Delete a Volume ...... 155 Link Volumes...... 156 Amendments and Restrictions ...... 158 How to … Add, Change, or Remove Amendments ...... 158 Add, Change, or Remove Restrictions ...... 159

iv Table of Contents

Encounter List ...... 160 How to … View Encounter List ...... 161 Add New Encounter ...... 162 Reassign an Encounter ...... 163 View History ...... 164 Delete an Encounter...... 165

Chapter 6  Working With Encounters Finding Existing Encounters...... 167 Import Encounters ...... 168 Regroup Inpatient Records...... 170 Regroup Outpatient Records ...... 170 Using the Real-Time Interface ...... 171 Receiving Encounters Through the Real-Time Interface for Regrouping ...... 172 Advanced Search for Encounter...... 173 Work on Encounters ...... 174 About the View Encounters Screen ...... 175 Creating a New Patient Encounter ...... 179 Opening an Existing Patient Encounter ...... 180 How to … Open an Encounter for a Patient Already in the Database...... 180 Open an Encounter from the Interlink Interface ...... 181 Entering Patient Encounter Information ...... 181 Demographic Information...... 182 Administrative Information ...... 182 Visit Characteristics ...... 182 Financial Information ...... 183 Icons from the Coding Screen ...... 184 How to … Enter Encounter Notes ...... 185 View Encounter History ...... 187 Copy Codes ...... 188 Managing Electronic Documents ...... 190 How to … Access Electronic Documents ...... 190 Work With Electronic Documents ...... 191 Completing the Coding Process on Encounters...... 192 How to … Save an Encounter ...... 192

v Clintegrity Coding/Abstracting User Guide

Export Encounters...... 193 Deleting Encounters ...... 195 How to … Delete Encounters...... 195 Standard Forms...... 196 Creating and Printing Forms ...... 196 How to … Create a Custom Form ...... 198 Print the Form ...... 198

Chapter 7  Using the Code Books Overview of Code Books ...... 200 Features on Alphabetic Indexes, ICD-10 PCS Tables, and Tabular Lists ...... 201 Visual Overview of Indexes...... 202 Visual Overview of the Tabulars Lists and PCS Table ...... 206 Selection in the Indexes, Tables, and PCS Tables...... 212 Navigating In the Index and Tabular ...... 216 How to … Move Around in the Index and Tabular...... 216 Tabular Details ...... 217 Cross References ...... 219 Working with ICD-10 CM Code Book...... 220 How to … Use the Find All-Index Search ...... 220 Use the Find All-Tabular Search...... 221 Tables in the ICD-10 CM Diagnosis Index ...... 223 How to … View an Entry in the Neoplasm Table...... 223 View an Entry in the Drugs and Chemical Table...... 224 View an Entry in the External Cause Index...... 225 Working with ICD-10 PCS Code Book ...... 226 How to … Use the Find All-Index Search ...... 226 Use the Table Search ...... 228 Using Standard Search in ICD-10 CM and PCS Code Books ...... 229 How to … Search for a Main Term ...... 229 Search for Main Terms and Subterms at the Same Time...... 229 Search for a Subterm After Locating a Main Term ...... 230 vi Table of Contents

Using Smart Search in ICD-10 CM and PCS Code Books ...... 231 Using Smart Search for PCS Synonyms ...... 233 Partial code search ...... 233 Full code search...... 235 Term search...... 236 Using the Indexes...... 237 Acting on Terms You Find in the Indexes...... 237 How to … Link to the Term's Code in the Tabular...... 237 Link to a Cross Reference ...... 237 View Additional Information for a Term ...... 237 Tables in the ICD-9 Diagnosis Index ...... 238 How to … View an Entry in the Hypertension Table ...... 238 View an Entry in the Neoplasm Table ...... 239 View an Entry in the Drugs and Chemical Table ...... 240 Using the Tabulars ...... 240 Searching for Codes in the Tabulars ...... 240 Searching for out of sequence Codes in the Tabulars ...... 241 Acting on Entries You Find in the Tabulars ...... 243 How to … Add a Code or Code Modifier to the Codelist ...... 243 View More Information for a Code ...... 244 View the Tabular Details for an ICD-9 Code ...... 244 Working in Code Books...... 244 Linked Codes ...... 244 Crosswalk...... 245 ICD-10 Crosswalk ...... 246 Crosswalk Pop-up ...... 246 Using Crosswalk ...... 247 Code Connection ...... 249 Using Code Connection...... 251 General Equivalency Mappings (GEM) ...... 252 QLines ...... 254 Synonyms...... 255 Smartips ...... 255 Appendixes...... 255

vii Clintegrity Coding/Abstracting User Guide

Using Context Menu in the Codes Panel ...... 256 Using Context Menu in Codebooks...... 258

Chapter 8  Reference Books Navigating Through Reference Books ...... 259 How to … Select a Specific Reference ...... 259 Understand Reference Book Display ...... 260 Searching Within the Reference Books ...... 260 How to … Search Anatomy Reference ...... 262 Search ICD-10 CM Guidelines Reference ...... 263 Search ICD-10 Coding Clinic Reference...... 264 Search ICD-10 PCS Reference ...... 267 Search ICD-10 PCS Reference Manual Reference ...... 268 Search ICD-10 PCS Guidelines Reference ...... 269 Search Clinical Indicators Reference ...... 270 Search Coding Clinic Reference...... 271 Search CPT Assistant Reference ...... 273 Search ICD-9 Guidelines ...... 274 Search Lab Values Reference ...... 275 Search Drug Reference ...... 276 Search Medical Dictionary Reference...... 277 Search Coding Clinic for HCPCS ...... 277 Search Abbreviations, Acronyms and Symbols ...... 278 Search GEM Reference ...... 279 Search Faye Brown...... 280 Search ICD-10 Handbook...... 281 Search Coder’s Desk References...... 283 Search Interventional Radiology Coding...... 284

Chapter 9  Codelist Overview of the Codelist ...... 287 Code Types and Lists...... 289 Code Packages...... 289 Code Builders ...... 289 Code Modifiers ...... 289 Adding Codes to the Codelist ...... 291 How to … Search for a Code From the Codelist ...... 291 Add a Code as an Admitting Diagnosis Code...... 292 viii Table of Contents

Directly Code an Admitting Diagnosis ...... 292 Add ICD-9, ICD-10, or CPT/HCPCS Codes to the Codelist ...... 292 Add Linked Codes to the Codelist ...... 293 Add Linked Codes from the ICD-9 Index ...... 293 Add Linked Codes from the ICD-9 Tabular ...... 293 Add Code Packages to the Codelist...... 293 Add Codes From the Code Builder...... 295 Add CPT Code Modifiers to the Codelist ...... 296 Type a CPT Code Modifier Directly Into The Codelist ...... 296 Add Condition Codes ...... 296 Modifying Codes in the Codelist...... 298 How to … Move Secondary Diagnosis to Principal Diagnosis ...... 298 Move Secondary Procedure to Principal Procedure...... 298 Copy a Code from the Dx List to the ADx...... 298 Copy a Code from the Codelist to the Reason for Visit ...... 299 Add or edit the Edit Episode Info ...... 299 Delete a Code from the Codelist ...... 300 Change a Code Modifier...... 300 Entering Additional Procedure Information...... 301 How to … Enter Procedure Codes Information ...... 301 Using the Editor ...... 303 View Edit Messages ...... 304 How to … Correct Errors and Warnings ...... 304

Chapter 10  Grouping and Pricing How to … Generate Reimbursement Amounts ...... 307 Calculate APCs ...... 307 View APC Detail ...... 309 Calculate ASCs ...... 310 Shuffle Codes ...... 310 View APR DRG Detail for a 3M™ Licensed Grouper ...... 312 Use Alternate DRGs ...... 314 DRG Pro...... 315 How to … View Target DRGs and Their Requirements ...... 316 Find Codes That Fulfill Unmet Requirements...... 317 Close the DRG Pro Window ...... 317 Store and Use a Second DRG Grouper ...... 318

ix Clintegrity Coding/Abstracting User Guide

Chapter 11  Reports Processing Reports ...... 320 How to … Create Reports ...... 320 Schedule Reports ...... 323 How to … Set Report Schedule...... 324 Edit Schedule ...... 325 View Schedule History ...... 326 Ad-Hoc Reports...... 327 How to … Create, or change, an Ad-Hoc Report...... 327 Run the Ad-Hoc Reports...... 327 Schedule Reports ...... 328 How to … Set Report Schedule...... 328 Edit Schedule ...... 329 View Schedule History ...... 329 Reports by Category...... 330 Encounter Reports ...... 330 APC Reports ...... 330 EAPG Reports...... 331 DRG Reports...... 331 Productivity Reports ...... 332 Physician Coding Reports...... 332 Custom Coding Reports ...... 332 HL7 Database Reports ...... 333 Coding Summary Report...... 333 Remote Grouper Reports ...... 333 Encounter Status Reports...... 333 APR DRG Reports ...... 333

Appendix A  Physician Coding Overview ...... 335 Components ...... 336 Admin Setup ...... 336

x Table of Contents

Preferences Setup ...... 336 Viewing Edit Messages ...... 337 How To Correct Errors and Warnings ...... 338 Setting up Physician Encounter ...... 339 Coding the Physician Record ...... 340 HCPCS Codes...... 340 Filter by Provider ...... 341 Line Item Billing ...... 341 Adding Codes from the E & M Code Builder ...... 342 E&M Calculation Confirmation ...... 345 Medical Necessity Policy Example...... 346 Smartips for Physician Coding ...... 346 Entering Additional Procedure Information...... 347 How to … Enter Procedural Info ...... 347 Edit Episode Info ...... 349 Copy Previous Episode Info ...... 350 Modifying Codes in the Codelist...... 350 How to … Change a Code's Description in the Codelist ...... 351 Copy a Code from the ADx to the PDx...... 351 Move Secondary Diagnosis to Principal Diagnosis ...... 351 Copy a Code from the Dx List to the ADx...... 351 Copy a Code from the Codelist to the Reason for Visit ...... 352 Delete a Code from the Codelist or Quick List ...... 352 Delete All Codes From the Dx, Px, or CPT lists ...... 352 Duplicate a Procedure Code ...... 353 Change the Order of Codes Within a List...... 353 Change a Code Modifier...... 353 Copy a Code Modifier...... 353 References ...... 353 Reports...... 354 Glossary ...... 355

xi Clintegrity Coding/Abstracting User Guide

Appendix B  Keyboard Shortcuts Code List Navigation Keyboard Shortcuts...... 359 General Navigation Keyboard Shortcuts ...... 360 Working in Code Books Keyboard Shortcuts ...... 361 Coding View Keyboard Shortcuts ...... 361 Date Keyboard Shortcuts...... 362 Navigation Keyboard Shortcuts ...... 362

Appendix C  Keywords for Standard and Custom Forms Standard Forms and Keywords...... 364 Coding Summary Form...... 364 Coding Summary Form General Keywords ...... 365 Coding Summary Form Encounter Keywords...... 366 ICD-10 Coding Summary Form...... 371 ICD-10 Coding Summary Form General Keywords ...... 371 ICD-10 Coding Summary Form Encounter Keywords ...... 372 How to … Print the ICD-10 Coding Summary ...... 374 ICD-10 Inpatient Billing Form ...... 375 ICD-10 Inpatient Billing Form General Keywords ...... 375 ICD-10 Inpatient Billing Form Encounter Keywords ...... 376 ICD-10 Outpatient Billing Form ...... 379 ICD-10 Outpatient Billing Form General Keywords...... 379 ICD-10 Outpatient Billing Form Encounter Keywords...... 380 ICD-10 Physician Attestation Form...... 383 ICD-10 Physician Attestation Form General Keywords ...... 384 ICD-10 Physician Attestation Form Encounter Keywords...... 385 Inpatient Billing Form ...... 388 Inpatient Billing Form General Keywords ...... 389 Inpatient Billing Form Encounter Keywords ...... 390 Outpatient Billing Form ...... 394 Outpatient Billing Form General Keywords...... 394 Outpatient Billing Form Encounter Keywords ...... 395 Physician Attestation Form ...... 399 xii Table of Contents

Physician Attestation Form General Keywords ...... 400 Physician Attestation Form...... 401 Physician Attestation Form General Keywords ...... 402 Physician Attestation Form Encounter Keywords ...... 403 ICD-10 Physician Billing Form ...... 407 Physician Billing Form General Keywords...... 407 Physician Billing Form Encounter Keywords ...... 408 Physician Query Form ...... 412 Physician Query Form General Keywords...... 413 Physician Query Form Encounter Keywords ...... 414 Abstracting Summary Form ...... 418 Abstracting Summary Form General Keywords...... 419 Abstracting Summary Form Encounter Keywords...... 419 ICD-10 Abstracting Summary Form ...... 425 ICD-10 Abstracting Summary Form General Keywords ...... 425 ICD-10 Abstracting Summary Form Encounter Keywords...... 426 General Keywords ...... 430 Encounter Keywords ...... 431

Appendix D  Synonyms Standard Synonyms...... 439 CPT Procedures Index ...... 439 ICD-9 Diagnosis Index ...... 444 ICD-9 CM External Cause Index ...... 452 ICD-9 Procedures Index...... 453 ICD-10 CM Index ...... 458 ICD-10 PCS Index ...... 468

Appendix E  Search Tips General Search Information ...... 471 Types of Searches ...... 471 Single-Term Search ...... 471 Multiple-Term Search (FTE)...... 472 Tips for FTE Searching ...... 472

xiii Clintegrity Coding/Abstracting User Guide

Comma-Delimited Search...... 473 Tips for Comma-Delimited Searching ...... 473 Find All - Index Search ...... 473 Advanced Search Criteria for Selection Rules...... 474 Setting Rule Condition Criteria ...... 474 Example A...... 475 Example B...... 476 Example C...... 477

Appendix F  Comparison of Edits Regulatory ...... 480 Data Quality Edits ...... 506 Revenue Edits ...... 508 Custom Rules ...... 508

Appendix G Coding Acronyms ...... 509

Appendix H  Location of ICD10 General Validation edits within ICD9 General Val- idation

Index ...... 519

xiv List of Tables List of Tables Table 1: Patient Information Banner Fields and Descriptions ...... 21 Table 2: Codes Panel - General Fields and Descriptions ...... 24 Table 3: Displayed Code Grid Buttons and Sequence of Display based on Display Settings options .29 Table 4: Displayed Code Grid Buttons and Sequence of Display based on Payor and Display Settings op- tions ...... 33 Table 5: CM and DX Code Grid Column Heading and Descriptions ...... 37 Table 6: PCS, PX and CPT/HCPCS Code Grid Column Heading and Descriptions ...... 37 Table 7: Clintegrity Icons and Descriptions ...... 41 Table 8: Coding Specific Icons and Descriptions ...... 43 Table 9: ICD-9 and HCPCS Books Search Types and Descriptions ...... 48 Table 10: ICD-10 CM and PCS Codebooks Search Types and Descriptions ...... 49 Table 11: Display Settings options ...... 49 Table 12: E&M Calculator Options and Descriptions ...... 52 Table 13: Default Tab Preferences and Descriptions ...... 52 Table 14: Basic Interface Settings and Descriptions ...... 55 Table 15: Compliance Inpatient and Outpatient Integration Options and Descriptions ...... 55 Table 16: HL7 Inbound and HL7 Outbound Settings Options and Descriptions ...... 56 Table 17: Field Settings and Descriptions ...... 58 Table 18: Coding Shuffle Settings and Results ...... 63 Table 19: Coding Variables and Descriptions ...... 72 Table 20: Synonym Specification Fields and Descriptions ...... 74 Table 21: Synonym Search Types and Descriptions ...... 75 Table 22: Smartips Specification Fields and Descriptions ...... 78 Table 23: Smartips Search Types and Descriptions ...... 79 Table 24: Code Package Specification Fields and Descriptions ...... 82 Table 25: Alternate Descriptions Specification Fields and Descriptions ...... 84 Table 26: Coding Status Fields and Descriptions ...... 86 Table 27: IP Selection Rule Criteria and Descriptions ...... 91 Table 28: ICD-10 IP Selection Rule Criteria and Descriptions ...... 94 Table 29: OP Selection Rule Criteria and Descriptions ...... 97 Table 30: ICD-10 OP Selection Rule Criteria and Descriptions ...... 100 Table 31: Legend Icons and Descriptions ...... 101 Table 32: IP Data Rules Groups and Descriptions ...... 104 Table 33: OP Data Rules Groups and Descriptions ...... 108

xv Clintegrity Coding/Abstracting User Guide

Table 34: Medicare Code Edits and Descriptions ...... 111 Table 35: ICD-10 Relational Code Edit and Descriptions ...... 113 Table 36: ICD-10 QCheck Edit and Descriptions ...... 114 Table 37: ICD-10 Relational Code Edit and Descriptions ...... 117 Table 38: ICD-10 QCheck Edit and Descriptions ...... 118 Table 39: Physician Rule Setting Groups and Descriptions ...... 121 Table 40: Physician Rule Setting ICD-10 Group and Descriptions ...... 125 Table 41: File Layout Specification Fields and Descriptions ...... 127 Table 42: File Layout Fields and Descriptions ...... 128 Table 43: Custom References Fields and Descriptions ...... 130 Table 44: Schedule Information Fields and Descriptions ...... 133 Table 45: Export Setting Fields and Descriptions ...... 136 Table 46: View Patient Search Options and Descriptions ...... 142 Table 47: Patient Information Banner Fields and Descriptions ...... 144 Table 48: Merge Action Columns ...... 145 Table 49: Amendment Fields and Descriptions ...... 159 Table 50: Restrictions Fields and Descriptions ...... 160 Table 51: Encounter List Fields and Descriptions ...... 161 Table 52: Add New Encounters Fields and Descriptions ...... 162 Table 53: Reassign Lookup Fields and Descriptions ...... 164 Table 54: History Lookup Fields and Descriptions ...... 164 Table 55: Encounter List Columns and Descriptions ...... 177 Table 56: Demographic Information Fields and Descriptions ...... 182 Table 57: Administrative Information Fields and Descriptions ...... 182 Table 58: Visit Characteristics Fields and Descriptions ...... 182 Table 59: Financial Information Fields and Descriptions ...... 183 Table 60: Encounter Notes Fields and Descriptions ...... 185 Table 61: Encounter History Lookup Fields and Descriptions ...... 187 Table 62: Delete Encounters Fields and Descriptions in Coding ...... 195 Table 63: Code Books and Descriptions ...... 200 Table 64: Index and Tabular Keystrokes and Descriptions ...... 216 Table 65: ICD-9 CM Tabular Fields and Descriptions ...... 217 Table 66: ICD-10 CM Tabular Fields and Descriptions ...... 218 Table 67: CPT Tabular Fields and Descriptions ...... 219 Table 68: Table Search Terms and Descriptions ...... 223 Table 69: Shortcuts used to display Tables and External Cause Index ...... 232

xvi List of Tables

Table 70: List of out of sequence codes ...... 241 Table 71: Code Connection Types and Actions ...... 251 Table 72: Context Menu Options and Actions in Code Grid ...... 256 Table 73: Context Menu Options and Actions in Codebook ...... 258 Table 74: PCS Codes - Additional Fields and Descriptions ...... 301 Table 75: HCPCS Codes - Additional Fields and Descriptions ...... 301 Table 76: APC Detail Fields and Descriptions ...... 309 Table 77: APR DRG Detail Fields and Descriptions ...... 312 Table 78: Relative Dates and Examples ...... 323 Table 79: Report Schedule Fields and Descriptions ...... 325 Table 80: Print Schedule Fields and Descriptions ...... 326 Table 81: Code List Navigation Keyboard Shortcuts ...... 359 Table 82: General Navigation Keyboard Shortcuts ...... 360 Table 83: Working in Code Books Keyboard Shortcuts ...... 361 Table 84: Coding View Keyboard Shortcuts ...... 361 Table 85: Date Keyboard Shortcuts ...... 362 Table 86: Navigation Keyboard Shortcuts ...... 362 Table 87: Coding Summary Form General Keywords ...... 365 Table 88: Coding Summary Form Encounter Keywords ...... 366 Table 89: ICD-10 Coding Summary Form General Keywords ...... 371 Table 90: ICD-10 Coding Summary Form Encounter Keywords ...... 372 Table 91: ICD-10 Inpatient Billing Form General Keywords ...... 375 Table 92: ICD-10 Inpatient Billing Form Encounter Keywords ...... 376 Table 93: ICD-10 Outpatient Billing Form General Keywords ...... 379 Table 94: ICD-10 Outpatient Billing Form Encounter Keywords ...... 380 Table 95: ICD-10 Physician Attestation Form General Keywords ...... 384 Table 96: ICD-10 Physician Attestation Form Encounter Keywords ...... 385 Table 97: Inpatient Billing Form General Keywords ...... 389 Table 98: Inpatient Billing Form Encounter Keywords ...... 390 Table 99: Outpatient Billing Form General Keywords ...... 394 Table 100: Outpatient Billing Form Encounter Keywords ...... 395 Table 101: Physician Attestation Form General Keywords ...... 400 Table 102: Physician Attestation Form General Keywords ...... 402 Table 103: Physician Attestation Form Encounter Keywords ...... 403 Table 104: Physician Billing Form General Keywords ...... 407 Table 105: Physician Billing Form Encounter Keywords ...... 408

xvii Clintegrity Coding/Abstracting User Guide

Table 106: Physician Query Form General Keywords ...... 413 Table 107: Physician Query Form Encounter Keywords ...... 414 Table 108: Abstracting Summary Form General Keywords ...... 419 Table 109: Abstracting Summary Form Encounter Keywords ...... 419 Table 110: ICD-10 Abstracting Summary Form General Keywords ...... 425 Table 111: ICD-10 Abstracting Summary Form Encounter Keywords ...... 426 Table 112: General Keywords and Descriptions ...... 430 Table 113: Encounter Keywords and Descriptions ...... 431 Table 114: CPT Procedures Index and Synonyms ...... 439 Table 115: ICD-9 Diagnosis Index and Synonyms ...... 444 Table 116: ICD-9 CM External Cause Index and Synonyms ...... 452 Table 117: ICD-9 Procedures Index and Synonyms ...... 453 Table 118: ICD-10 CM Index and Synonyms ...... 458 Table 119: Regulatory Edits Table ...... 481 Table 120: Data Quality Edits Table ...... 506 Table 121: Revenue Edits Table ...... 508 Table 122: Custom Rules Table ...... 508 Table 123: Coding Acronyms ...... 509 Table 124: General Validation Rules for IP Rule Settings ...... 513 Table 125: General Validation Rules for OP Rule Settings ...... 514 Table 126: General Validation Rules for Physician Rule Settings ...... 516

xviii What’s New What’s New

ENHANCEMENT PAGE

No significant changes in the 18.3 release.

xix Chapter 1 About Clintegrity Coding and Abstracting

Chapter 1  About Clintegrity Coding and Abstracting

Welcome to the Coding/Abstracting User Guide. This introductory chapter provides an overview of Clintegrity Coding and Abstracting.

Features and Benefits

 Advantages of Coding (see page 2)

 Components of Coding (see page 3)

 Essentials of Coding (see page 3)

1 Clintegrity Coding/Abstracting User Guide

Advantages of Coding Clintegrity Coding and Clintegrity Abstracting are knowledge-based encoding solutions. They include the full text of all the official required code books that are used for inpatient and outpatient coding. The knowledge-based approach complies with the official guidelines, conventions, and structure of the International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) and International Classification of Diseases 10th Revision Procedure Classification System (ICD-10-PCS) for coding, and with the Official ICD-9-CM Guidelines for Coding.

NOTE: Clintegrity 360 maintains three years (current year and the previous two years) of the ICD-9-CM code book and facilitates the direct lookup of codes.

Clintegrity Coding and Clintegrity Abstracting use both the ICD9 volumes and the CPT book, in addition to the ICD-10-CM and ICD-10-PCS volumes. In fact, you do not have to learn any new coding methods—Clintegrity Coding and Clintegrity Abstracting use the same entries and formats as the books. However, Clintegrity Coding and Clintegrity Abstracting do provide some significant advantages:

 Alphabetic Indexes, PCS Tables, and Tabular Lists are connected through hyperlinks.

 Instructional notations and references are only a mouse-click away.

 If you need to see a cross reference in the Alphabetic Indexes, PCS Tables, or Tabular Lists, one keystroke or mouse click takes you there, and one brings you back. See Cross References.

 The editor watches for potential errors and ambiguous coding issues. See Using the Editor.

 The grouper enables you to make fast and accurate comparisons of alternative DRGs. See Generate Reimbursement Amounts.

 You can see a patient’s previous admission to check what was diagnosed and coded. The system stores multiple admissions for a single patient. See Opening an Existing Patient Encounter.

 Centralized encounter management updates the common data element values whenever you change them in any product. If an encounter is open in any product, it is locked (but viewable) in all other products. See Encounter List and Common Data Elements in Compliance User Guide.

2 Chapter 1 About Clintegrity Coding and Abstracting

Components of Coding Coding and Abstracting include:

 The complete text of the ICD-9, ICD-10-CM, and ICD-10-PCS volumes in a familiar format. See Search ICD-9 Guidelines.

 The complete text of the Physicians’ Current Procedural Terminology (CPT) volume in a familiar format. (CPT is a trademark of the American Medical Association.) See Search CPT Assistant Reference.

 Additional entries to help you code. See Appendixes.

 The Clintegrity Coding Editor which checks for accurate coding consistent with standard coding principles and guidelines. See Using the Editor.

 The Clintegrity Coding Grouper which groups selected codes and generates DRGs using the official Center for Medicare and Medicaid Services (CMS) algorithm, or alternate grouper algorithms (such as All Patient Grouper). See Generate Reimbursement Amounts.

 A patient database that stores your hospital’s medical records for fast and easy retrieval.

Essentials of Coding Clintegrity Coding and Clintegrity Abstracting enables you to code using a variety of methods; these methods are discussed in detail throughout this User Guide. You choose the one that works best for you. Below are some common step that you will need to use.

1. Open an existing patient record or create a new one.

2. For a new patient, enter information about the patient in the Coding Patient Info page.

3. Lookup diagnoses or procedures in the ICD-9, ICD-10 code book, or CPT indexes. Once you have found terms, you can either select the code from the screen or manually add the code.

4. Use the Tabular List or PCS Tables to review codes and clinical advice, and to add codes to the Codelist. If you have codes in the Pending Codes list, you can quickly run through them.

5. Review references such as GEM, ICD-10 CM Coding Guidelines, or ICD-10 PCS Reference Manual. Continue to add or modify codes to complete the encounter.

6. Respond to Edit messages. Edit messages are notifications of errors or advice that appear to help you code the record accurately.

7. Group the record to calculate reimbursement.

8. Complete the coding session and save the encounter.

3 Clintegrity Coding/Abstracting User Guide

About the Coding and Abstracting Labels This guide discusses Clintegrity Coding and Clintegrity Abstracting because these two products behave in essentially the same way.

 Your facility can have Clintegrity Coding without Clintegrity Abstracting. If you only have Clintegrity Coding, the access tab in Clintegrity is labeled Coding.

 Your facility cannot have Clintegrity Abstracting without Coding. Clintegrity Abstracting are enhancements to Clintegrity Coding, with additional features. If you have Coding and Abstracting or only Coding and Abstracting, the access tab in Clintegrity is labeled Coding/Abstracting.

However, in this guide you will see the product name usually referred to as  Clintegrity Coding/Abstracting. Understand this to mean whichever product your facility is using. In some of the graphics, the tab labels might differ from what you see on your page. Your ability to understand and follow the instructions should not be affected by differences of labels.

4 Chapter 2 Getting Started

Chapter 2 Getting Started

This chapter covers some initial steps you need to take before using Clintegrity.

 Enable Clintegrity Keystrokes in Flat Panel Monitors (see page 5)

 Configuring Your Browser (see page 6)

 Signing In (see page 14)

 Configuring Users (see page 19)

Enable Clintegrity Keystrokes in Flat Panel Monitors If you want to use application keyboard shortcuts, disable the hot keys settings. See your monitor user guide for instructions on changing hot key settings.

CAUTION: Some flat-panel monitors have settings that conflict with application keyboard shortcuts. These monitors may have hot keys available that allow the screen display to flip to a sideways view. If these hot keys are enabled, you lose the ability to use keyboard shortcuts within the application.

5 Clintegrity Coding/Abstracting User Guide

Configuring Your Browser Clintegrity uses Microsoft Internet Explorer as its Web browser. For the application to function properly, you need to configure your browser to display the correct font size, use the proper settings, and get updated pages every time it connects to the server.

How to ...

 Set Standard Browser Settings (see page 6)

 Configure Security Settings (see page 7)

 Set Print Page Options (see page 11)

 Set Recommended Options (see page 11)

 Set Custom Links (see page 13)

Set Standard Browser Settings

NOTE: Verify that you are not signed in to Clintegrity when configuring browser.

1. Start Internet Explorer.

2. Configure the Internet options as follows:

a. Select Tools\Internet Options.

b. On the General tab, in the Temporary Internet Files or Browsing History section, click Settings.

c. From the Check for newer versions of stored pages, select one of the following radio buttons:  Every Visit To The Page or Every time I visit the webpage – If you use Electronic Document Management or File Manager and the server is in a different time zone than the workstation, or if you use eSignature.  Automatic or Automatically – If the above conditions do not apply to your facility.

d. Click OK to close the Settings window and apply the change.

NOTE: For Compliance, click the Advanced tab and select Print background colors and images in the Printing section. This enables background color printing for post-audit worksheets.

e. Click OK to close the Internet Options window.

3. Configure the text size by selecting View\Text Size\Medium.

4. Configure the encoding by selecting View\Encoding\Auto-Select.

6 Chapter 2 Getting Started

5. For Correspondence Management, configure the page setup as follows:

a. Select File\Page Setup.

b. In the Headers and Footers section, delete any entries in the Header and Footer fields.

6. Restart your browser to apply all settings.

CAUTION: The use of supplemental browser toolbars such as Yahoo! Companion or Google is not recommended with Clintegrity. You should remove or disable these toolbars when using Clintegrity.

Configure Security Settings Prior to running the application or integration, the following Internet Explorer settings must be set. These settings apply to any workstation that uses the application or integration, including both scan and view stations. There are many components that are loaded to the local machine when viewing images. If the Active X controls are not changed, then constant pop-ups appear while viewing images. The Clintegrity server is added as a trusted site, so that these settings apply only to  Clintegrity application, but do not affect other Internet or Intranet applications.

You can use the Internet Explorer Administration Kit (IEAK) provided by Microsoft to create and manage custom browser software packages with the application settings. When these packages are installed on clients’ desktops, they receive customized versions of Internet Explorer with the settings and options selected. After you deploy Internet Explorer, you can use the IEAK Profile Manager to change browser settings and restrictions automatically.

These settings apply only to Clintegrity, and do not affect other Internet or Intranet applications you use from your browser.

1. Take note of the location of the Clintegrity production server (and test server, if applicable). You can find the name of the location by opening the application and viewing the URL. The name appears after http:// and is followed by a colon.

2. In the Internet Explorer browser window, select Tools\Internet Options.

3. In the Internet Options window, click the Security tab.

See step 4

See step 7

Figure 1: Security Tab - Trusted Sites Settings

7 Clintegrity Coding/Abstracting User Guide

4. Click the Trusted Sites symbol and then click the Sites button.

5. In the Trusted Sites window, enter the following:

a. In the edit box located at top of the window, enter http:// (replace the with the name of your application server name). Then click the Add button. The name appears in the Web sites list.

Ensure to uncheck this checkbox.

Figure 2: Trusted Sites Window

b. Confirm that Require server verification… is unchecked. Uncheck if necessary.

6. Click OK or Cancel. From the Security tab with the Trusted Sites symbol selected, click the Custom Level button.

7. The Security Settings window opens.

Figure 3: Security Settings Window

8 Chapter 2 Getting Started

Make or verify the following selections:

a. Confirm that Medium is selected in the Reset to drop-down list and change if necessary.

b. In the ActiveX controls and plug Ins section, verify that the Enable radio button is selected for:  Allow Scriptlets (Internet Explorer 8.0 or higher)  Automatic prompting for ActiveX controls (Internet Explorer 8.0 or higher)  Download signed ActiveX controls In the Internet Options window, perform the following steps:  Initialize and script ActiveX controls not marked as safe for scripting (Internet Explorer 8.0 or higher)  Run ActiveX controls and plug-ins  Script ActiveX controls marked safe for scripting

c. For Electronic Document Management and File Manager, in the ActiveX controls and plug Ins section, verify that the Enable radio button is selected for the following:  Allow previously unused ActiveX controls to run without pop-ups (Internet Explorer 8.0 or higher)  Binary and script behaviors (Internet Explorer 8.0 or higher)  Only allow approved domains to use ActiveX without prompt (Internet Explorer 8.0 or higher)

d. Confirm that the Prompt radio button is selected for the Download unsigned ActiveX controls setting (enable if using Electronic Document Management or File Manager).

e. In the Miscellaneous section, select Enable for Allow script-initialized windows without size or position constraints (Internet Explorer 8.0 or higher).

f. For Electronic Document Management and File Manager, in the Miscellaneous section, select Enable for the following:  Access data sources across domains  Allow META REFRESH (Internet Explorer 8.0 or higher)  Allow scripting of Internet Explorer Web browser control (Internet Explorer 8.0 or higher)

g. For File Manager, in the Downloads section, select Enable for the Automatic prompting for file downloads setting (Internet Explorer 8.0 or higher).

8. Click OK to return to the Internet Options window.

9. You can disable the pop-up blocker only for Clintegrity by entering your application server name

9 Clintegrity Coding/Abstracting User Guide

a. Click the Privacy tab and then click the Settings button next to the Block pop-ups checkbox.

Figure 4: Internet Options Window - Privacy Tab

b. In the edit box located at top of the window, enter the name of your application server.

c. Click the Add button. The name appears in the Allowed sites list.

Figure 5: Pop-up Blocker Settings Window

10. Click Close to return to the Internet Options window.

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11. Set the following additional settings in the Security tab if you are using Internet Explorer 8.0 with the Windows Vista or Windows 7 operating system: If an Internet Web site is set as your homepage:

a. Click the Internet zone.

b. Click the Enable Protected Mode checkbox to select it.

Click here

Figure 6: Security Tab - Internet Settings

12. If the application web site or another local Intranet page is set as your homepage:

a. Click the Local Intranet zone.

b. Click the Enable Protected Mode checkbox to select it.

NOTE: For both the Internet and Local Intranet zone, turn off the User Account Control (UAC) setting under Control Panel\User Accounts. This helps you to avoid script errors during a scan save.

13. Click OK.

 The window closes and you are returned to Internet Explorer.

 The settings now take effect.

Set Print Page Options When you print from Clintegrity applications, you can change the appearance of the page.

1. From your browser, select File\Page Setup.

2. Select your preferred settings and click OK.

Set Recommended Options These settings are recommended for the best use of Clintegrity.

11 Clintegrity Coding/Abstracting User Guide

Block Debugger

1. Block debugger error messages by adjusting two settings:

a. In your browser, select Tools\Internet Options.

b. Click the Advanced tab.

c. Check Disable script debugging for Internet Explorer and Other.

d. Uncheck Display a notification about every script error.

Multiple Windows

1. If you want to open a new web site in a separate window while keeping the application open in its own window, uncheck Reuse windows for launching shortcuts.

2. Click OK to save the settings and close the Internet Options window.

Disable Toolbars

1. Disable any supplemental browser toolbars such as Yahoo! Companion or Google:

a. Select View\Toolbars.

b. On the list of toolbars, uncheck the relevant toolbar.

12 Chapter 2 Getting Started

Set Custom Links All users have access to system-wide Internet links to different Web sites. If you have permission to access the Internet you can add or remove these links. Each user can add personal links.

You may now open Clintegrity systemwide links and your list of custom links from within any Clintegrity function. Click the Links tab in the main navigation bar and your links in a pop-up window appear.

To set custom links:

1. On the main Clintegrity page, select Links from the Application menu in the upper right-hand corner of the page to open the Custom Links page.

Enter the web address.

Then enter a description.

Select whether the site is System Wide Click Save. (available to all users) or Personal (available to you only).

Figure 7: Custom Links Page

2. In the URL field, enter the web address of the Internet site you want to connect to. You must include the complete address, including the http://.

3. In the Description field, enter a description of the site, for example, My hospital’s web site. 4. Select a radio button for the kind of link that the site is, either System Wide or Personal.

5. Click Save to add the link

See Navigating with Links for more information on the Remote Support Connection link.

13 Clintegrity Coding/Abstracting User Guide

Signing In Before you start, your system administrator must set up an account for you.

If you try to sign in and receive a message that the user limit has been reached, you need to wait and try again later. (Each installation of Clintegrity operates on a concurrent user license. That means that there is a limit to how many users can be signed into the system at the same time. The limit is different for every institution.)

Each time you finish working in the application, click the Signout button in the upper right corner of the page. Signing out removes you from the group of current users and enables other users to sign in to the system.

How to ...

 Start the Clintegrity Application (see page 14)

 Standard Sign In (see page 15)

 First Time Sign In (see page 15)

 Rules for Creating Passwords (see page 16)

 Changing the user password from the Home Page (see page 16)

 Get Help Signing In (see page 18)

Start the Clintegrity Application You launch the application by either of these methods.

 Start your web browser and then do one of the following (if Clintegrity is set as your home page, the sign-in page appears when you open your browser).

 Enter the Clintegrity home page URL in the Address field.

 If Clintegrity is in your favorites list, select it from the Favorites drop-down list.

 If you have a Clintegrity 360 Client icon or a Clintegrity 360 shortcut icon on your desktop,  double-click on it.

14 Chapter 2 Getting Started

Standard Sign In This is the standard process for signing in to the application.

NOTE: If you are signing in for the first time, follow the instructions in First Time Sign In (see page 15).

1. Start the application. The Sign In Center page appears. Clintegrity Sign In Center:

Figure 8: Clintegrity Sign In Center Screen

2. Enter your User ID in the User ID field. If you do not know you User ID, ask your system administrator.

3. Enter your password in the Password field. If your password does not work or you cannot remember it, click the Need Help Signing In? link. See Get Help Signing In (see page 18).

4. Click the Sign In button to open the Homepage.

5. At the top of the page, click the tab of the application you want to use.

First Time Sign In If this is your first time signing in, follow these steps.

1. Enter the password your system administrator assigned to you in the Password field.

2. Click Sign In.

3. Change your password, as follows (see also Rules for Creating Passwords (see page 16)).

a. Type the password you used to enter the system in the Old Password field.

b. Enter your own new password in the New Password field.

c. Re-enter your new password in the Confirm Password field. Use this new password each time you sign in.

4. Click Sign In. If you cannot sign in, click the Need Help Signing In? link. See Get Help Signing In (see page 18).

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Rules for Creating Passwords Use these rules when creating a password.

 Choose a password that is easy for you to remember, but difficult for others to guess. Avoid using your name or the names of family members, familiar dates, such as birthdays, or common words, such as password or key.

 The passwords of all users (except the Administrator) must comply with the following rules that define a strong password. It must be between 8 and 128 characters in length and must include at least three out of the following four criteria:

 Upper case letter

 Lower case letter

 Digit

 Special character

 Apart from the above rules, the password cannot be same as n previous passwords. The value of n can be modified by the administrator. The default value is 10. The administrator can set any value between 1 to 24, through the back-end script.

 Passwords are case sensitive. For instance, Pb2Ag and pb2ag are different passwords. To make your password more secure, use a mixture of uppercase and lowercase letters.

 Never share your password, not even with friends or colleagues.

 Never leave your password lying around or on notes near your computer. NOTE: The guidelines to choose a secure password are displayed when you try to set up a new password.

Changing the user password from the Home Page The user can change his own password from the home page, by using the Change Password link.

1. Click the Change Password link.

Figure 9: Change Password screen

2. Enter the old password.

3. Enter the new password in the New Password and the Confirm New Password field.

4. Click Update to update the password or click Cancel to return to the Home Page.

16 Chapter 2 Getting Started

When the password is changed successfully, the Home Page displays the password successfully changed message.

Figure 10: Home Page with Password change success message

Password Settings

 The maximum password age can be set up to 365 days.

 Password once changed can only be updated after minimum n days. Where, n is the number of days that can be configured by the administrator through back-end script. The default value is 1.

 While logging into the application, if you enter a wrong password for n number of times, your account will be locked out. Where, n is the maximum failed attempts allowed for logging into the application. This value can be configured by the administrator between 1 to 10 attempts, through the back-end script. By default this value will be set to 5 attempts.

 After the last failed login attempt the users account will stay locked out for n number of minutes. Where, n is the value between 15 to 120 minutes, set by the administrator in the Users that do not enter the correct password will not be able to Sign in for field in Admin\Preferences\Global System Preferences. By default this value will be set to 15 minutes. NOTE:

 The above conditions are applicable to both, users and Administrator.

 These are recommended setting and no validation is done on these settings.

17 Clintegrity Coding/Abstracting User Guide

Get Help Signing In If you have trouble signing in – because of some problem with your User ID or Password – click the Need Help Signing In? link below the Password field.

A pop-up opens with tips that might help you sign in correctly.

This page also provides information on contacting your system administrator, if you need further help to sign in.

Figure 11: Need Help Signing In Screen

NOTE: If you enter the incorrect User ID password combination, your account might be temporarily disabled. Contact your system administrator for assistance.

18 Chapter 2 Getting Started

Configuring Users You need to set up User Preferences before you can use the Clintegrity system. User preferences are global, meaning they apply to all the facilities within an enterprise. Depending upon your  Clintegrity configuration, you need to configure different preferences. In addition to general Clintegrity preferences, User Preferences for the specific Workflow enabled modules will also need to be set up.

See the Clintegrity System Administration Guide for more information on managing users and groups. Module specific guides should be referenced when the Workflow user is assigned to a module’s worklist. For example, See the Clintegrity Coding User Guide if a workflow user is assigned to a Coding worklist.

View Encounters Screen You can access View Encounters screen by selecting Coding/Abstracting\View Encounters.

Figure 12: View Encounters Screen

19 Clintegrity Coding/Abstracting User Guide

How to ...

Access Coding

1. Select Coding/Abstracting\View Encounters to open the View Encounters screen.

2. Use the relevant option in the Search drop-down list and also in the Advanced Search, Field drop- down list, to search for encounters.

3. Select an inpatient or outpatient encounter that you want to work on. The Coding screen displays.

Overview of Coding Screen

Patient Information Codes panel (see Coding and Abstracting Banner page 24) statuses with drop-down list

Figure 62: Overview of the Coding Screen

NOTE:

 The CM Code Grid and the PCS Code Grid displays on Codes panel only when you have the ICD-10 license and ICD-10 permissions.

 The icons in the Codes panel (above code list) display only when they are relevant to codes listed for an encounter.

 If you have the Abstracting license, then the Coding Status and Abstracting Status options display with the drop-down list and the Save button displays without the drop-down list.

20 Chapter 2 Getting Started

Patient Information Banner When you select an encounter, you are taken to the Coding screen that displays the Patient Information banner.

How to ...

Add or Change Patient Information You can collect and change all patient information on the Coding screen.

Show Patient Details button Edit Patient Details button

Figure 63: Coding Screen

1. In the Patient Information banner, click the Edit Patient Details icon to enter or update the patient information. ( )

Table 1: Patient Information Banner Fields and Descriptions

FIELD DESCRIPTION

For both inpatient and outpatient encounters (generic)

Patient Name Enter the patient’s name.

MRN Enter the medical record number used by the patient in the facility for which the patient is being created. Different facilities can use different MRNs for the same patient. The information in this field cannot be edited.

Account # Enter the account number. The information in this field cannot be edited.

Sex Select the patient’s sex from the drop-down list.

Age The value is auto-populated in this field.

*Patient Type Select the patient type from the drop-down list.

21 Clintegrity Coding/Abstracting User Guide

FIELD DESCRIPTION

Visit Type Select the visit type from the drop-down list.

Coder Select the coder from the drop-down list.

Payor (Primary) Select payor information from the drop-down list.

Secondary Payor Select secondary payor information from the drop-down list.

Total Charges Enter total charges.

Bill Type Enter the bill type information or click the Bill Type Lookup icon to choose a bill type from a pop-up window. ( )

For inpatient encounters

*AD Enter the admit date or click the Admit Date Calendar Lookup icon to choose a date from a calendar. ( )

DD Enter the discharge date or click the Discharge Date Calendar Lookup icon to choose a date from a calendar. ( )

Discharge Status Enter the discharge status or click the Discharge Status Lookup icon to choose a discharge status from a pop-up window. ( )

DRG The DRG value is auto-populated in this field. NOTE: If an HAC code is entered, then the Coding screen refreshed to display Initial DRG indicator (I) in the grouper drop-down list.

Version Select version from the drop-down list. NOTE: If the payor is not selected, then the version displays same grouper with P and S as suffix (for ICD-9 and ICD-10).

DOB Enter the patient’s birth date or click the Date Of Birth Calendar icon to choose a date from a calendar. ( )

Admit Time Enter the admit time.

Birth Wt Enter the birth weight.

Attending Enter the attending provider information or click the Provider Lookup icon to choose a provider from a pop-up window. ( )

Discharge Time Enter the discharge time.

Facility The facility field is auto-populated.

LOS The length of stay value is auto-populated (Admit Date - Discharge Date).

AMLOS Arithmetic Mean Length of Stay. A LOS that is calculated taking into account all LOSs. Used to compare to other hospitals. NOTE: The value is auto-populated.

GMLOS Geometric Mean Length of Stay. A LOS that is calculated taking into account geographic factors, cost outliers and transfers. NOTE: The value is auto-populated.

22 Chapter 2 Getting Started

FIELD DESCRIPTION

Weight The relative value established by CMS and NY State for DRG. NOTE: The value is auto-populated.

Secondary DRG The secondary DRG value is auto-populated only when you enter the secondary payor information.

Reimb The reimbursement amount is auto-populated.

For outpatient encounters

*FD Enter the From date or click the Admit Date Calendar Lookup icon to choose a date from a calendar. ( )

TD Enter the To date or click the Admit Date Calendar Lookup icon to choose a date from a calendar. ( )

Parent Account Enter the Parent Account Number.

From Time Enter the From time.

To Time Enter the To time.

APC Reimb The APC reimbursement amount is auto-populated.

Fac Reimb The facility reimbursement amount is auto-populated. NOTE: This option is hidden when you select the EAPG grouper.

ASC Reimb The ASC reimbursement amount is auto-populated.

APC Outlier The APC outlier amount is auto-populated.

NOTE:

 For inpatient encounters, the / (slash) is used as a separator for P and S and PR and SR in the Patient information banner.

 For outpatient encounters, the / (slash) is used as a separator for only P and S in the Patient information banner.

 When you select EAPG, the APC reimbursement options are hidden and the EAPG reimbursement information is displayed.

2. To save your changes, click the Done Edit icon. ( )

23 Clintegrity Coding/Abstracting User Guide

Codes Panel Based on the selected license, permissions, payor setups, and user preferences, the Codes Panel will display the Code Grid buttons for ICD-10 and ICD-9 codes. The Code Grid buttons are:

 CM Code Grid

 DX Code Grid

 PCS Code Grid

 PX Code Grid

 CPT/HCPCS Code Grid

Table 2: Codes Panel - General Fields and Descriptions

FIELD DESCRIPTION

Code Type Select a code type from the drop-down list

Search Enter search term/code you wish to search for

Search Type Select a search type from the drop-down list

Admitting Diagnosis (P) Enter the primary admitting diagnosis code

Admitting Diagnosis (S) Enter the secondary admitting diagnosis code

Reason for Visit (P) Enter the primary reason codes NOTE:

 You can enter upto 3 primary reason codes by clicking the + icon.

 You can press ENTER key to enter next Reason for Visit code.

Reason for Visit (S) Enter the secondary reason codes NOTE:

 You can enter upto 3 secondary reason codes by clicking the + icon.

 You can press ENTER key to enter next Reason for Visit code.

Diagnosis and Procedure Grids You can maximize/restore the Code Grid section with the and buttons. When the Code Grid section is maximized the Codes Panel section is hidden.

Multi-Panel View (Codebook and Code Grids) In the new multi-grid multi-panel view, when a code or term search is initiated, the Encounter screen is divided into two vertical panels. The right panel is used to display all the Code Grid buttons and the Code Grids. The left panel displays the codebook.

The placement of Diagnosis and Procedure Code Grid in Multi-Panel View (Codebook and Code Grids):

24 Chapter 2 Getting Started

 In multi-grid multi-panel view, the Diagnosis Code Grids are displayed on top of the Procedure Code Grids.

 The Code Grids sections can be maximized and minimized by clicking the and buttons, respectively.

 When the codebook is maximized the Code Grid panel will close, and vice versa.

Figure 64: Inpatient Encounter Multiple Panel View

Figure 65: Outpatient Encounter Multiple Panel View

 When you enter a code in the Code Search field, the codebook is displayed with the relevant search result. When the code is selected from the codebook the selected code appears in the first blank row of the relevant Code Grid. If the Code Grid for that code is not visible and is spanning out of view, the grids auto adjust to display the code added to the grid.

25 Clintegrity Coding/Abstracting User Guide

Show/Hide Code Grids

 The dark blue color shade and a check mark on the Code Grid buttons indicates that the Code Grid is shown. The light blue color shade of the Code Grid button without a check mark indicates that the Code Grid is hidden.

Figure 66: Show/Hide Code Grid buttons

 When a particular Code Grid is hidden and search for code or text related to it is initiated, the hidden grid will be shown. Refer to the example below. NOTE: The new sticky layout retains the Code Grid button selection that has been made by you, even when the screen is refreshed. Once the encounter is saved and reopened, the default screen will appear.

Example:

1. In the below image the PCS Code Grid is hidden. The PCS code type is selected in the Search drop-down list and 02B00ZZ code is entered in the Code Search field.

Figure 67: Hidden PCS Code Grid

2. When the search button is clicked, the PCS Code Grid is shown and the codebook displays the searched code.

Figure 68: PCS Code Grid shown

26 Chapter 2 Getting Started

3. To add the searched code to the PCS Code Grid, select the displayed/highlighted 02B00ZZ code in the codebook.

27 Clintegrity Coding/Abstracting User Guide

How to ...

 Show/hide Code Grids

1. To show Code Grids, click or press the ENTER key when the focus is on the Code Grid buttons.

Figure 69: All Code Grids shown - Example

2. To hide Code Grids, click or press the ENTER key when the focus is on the Code Grid buttons or click the button on the Code Grids.

.

Figure 70: All Code Grids hidden - Example

Code Grid in expanded view

When Codebooks panel are collapsed, the Code Grid panel expands. When the Code Gird panel is in the expanded state, the Diagnosis Code Grid is placed to the left and Procedure Code Grid is placed to the right. When the Code Grid is in an expanded view, the sequence of Code Grids and which Code Grids are shown/hidden depends on the criteria mentioned in the table below.

28 Chapter 2 Getting Started

Table 3: Displayed Code Grid Buttons and Sequence of Display based on Display Settings options

INPATIENT ENCOUNTERS: DISPLAYED OUTPATIENT ENCOUNTERS: DISPLAYED CHECKBOX CODE GRIDS BUTTONS AND SEQUENCE CODE GRIDS BUTTONS AND SEQUENCE OF DISPLAY OF DISPLAY

Display ICD-9 Procedure CM, DX, PCS, PX CM, DX, CPT/HCPCS, PX for Outpatient

Display ICD-10 PCS for CM, DX, PCS, PX CM, DX, CPT/HCPCS, PCS Outpatient Click here to see the example Click here to see the example view view

Display CPT/HCPCS for CM, DX, PCS, PX, CPT/HCPCS CM, DX, CPT/HCPCS Inpatient Click here to see the example Click here to see the example view view

All of the above CM, DX, PCS, PX, CPT/HCPCS CM, DX, CPT/HCPCS, PCS, PX checkboxes are selected Click here to see the example Click here to see the example view view

All of the above CM, DX, PCS, PX CM, DX, CPT/HCPCS checkboxes are deselected Click here to see the example Click here to see the example view view

NOTE: The above checkboxes can be selected in combination and the associated Code Grids are displayed.

Figure 71: View of an inpatient encounter with Display ICD-10 PCS for Outpatient checkbox selected - Example

29 Clintegrity Coding/Abstracting User Guide

Figure 72: View of an outpatient encounter with Display ICD-10 PCS for Outpatient checkbox selected - Example

Figure 73: View of an for inpatient encounter with Display CPT/HCPCS for Inpatient checkbox selected - Example

30 Chapter 2 Getting Started

Figure 74: View of an outpatient encounter with Display CPT/HCPCS for Inpatient checkbox selected - Example

Figure 75: View an inpatient encounter with all checkboxes selected - Example

31 Clintegrity Coding/Abstracting User Guide

Figure 76: View of an outpatient encounter with all checkboxes selected - Example

Figure 77: View of an inpatient encounter with no checkbox selected - Example

Figure 78: View of an outpatient encounter with no check box selected - Example

32 Chapter 2 Getting Started

Table 4: Displayed Code Grid Buttons and Sequence of Display based on Payor and Display Settings options

PAYOR INPATIENT ENCOUNTERS: DISPLAYED OUTPATIENT ENCOUNTERS: CODE GRIDS BUTTONS AND DISPLAYED CODE GRIDS BUTTONS SEQUENCE OF DISPLAY AND SEQUENCE OF DISPLAY

Blank Payor before 10/1/2015 DX, CM, PX, PCS, CPT/HCPCS DX, CM, CPT/HCPCS, PX, PCS

Blank Payor after 10/1/2015 CM, DX, PCS, PX, CPT/HCPCS CM, DX, CPT/HCPCS, PCS, PX Click here to see the example Click here to see the example view view

ICD-10 Payor selected CM, PCS, CPT/HCPCS CM, DX, CPT/HCPCS, PCS, PX Click here to see the example Click here to see the example view view

ICD-9 Payor selected DX, PX, CPT/HCPCS DX, CM, CPT/HCPCS, PX, PCS

Figure 79: View of a inpatient encounter with Admit date before 10/1/2015 - Example

33 Clintegrity Coding/Abstracting User Guide

Figure 80: View of a outpatient encounter with Admit date before 10/1/2015 - Example

Figure 81: View of a inpatient encounter with ICD-10 payor selected - Example

34 Chapter 2 Getting Started

Figure 82: View of a outpatient encounter with ICD payor selected - Example

The Code Grid buttons and sequence of Code Grids is also based on selection of the Primary Payor.

 In the Diagnosis Grid section, the CM Code Grid is placed above the DX Code Grid.

 For inpatient encounters in the Procedure Grid section, the PCS Code Grid is placed at the top followed by the PX and CPT/HCPCS Code Grids.

 For the outpatient encounters in the Procedure Grid section, the CPT/HCPCS Code Grid is placed on the top followed by the PCS and PX Code Grids.

 For inpatient encounters, the sequence of Code Grid buttons is CM, DX, PCS, PX, and CPT/ HCPCS.

Figure 83: Inpatient Encounter Grid Button Sequence

 For outpatient encounters, the sequence of Code Grid buttons is CM, DX, CPT/HCPCS, PCS, and PX.

35 Clintegrity Coding/Abstracting User Guide

Figure 84: Outpatient Encounter Grid Button Sequence

Figure 85: Outpatient Encounter Code Grid Placement - Example

Figure 86: Inpatient Encounter Code Grid placement - Example

 While adding codes to any of the Code Grid, if the grid rows span out of view, a vertical scroll bar is displayed. This scroll bar can be used to scroll through the hidden rows, while keeping the header row fixed.

36 Chapter 2 Getting Started

 If the number of columns in the PCS and CPT/HCPCS Code Grids are increased and the columns span out of view, a horizontal scroll bar is displayed.

 The TAB and SHIFT+TAB arrow keys can be used to navigate through Admit Diagnosis (P/S) fields, Reason for Visit fields and all Code Grids. Read-only fields and hidden Code Grids will be skipped. For more information about using keyboard shortcuts, refer to Keyboard Shortcuts

 When the Display Condition Codes & Revenue Codes checkbox is selected and when Procedure Grids are shown, the Condition codes are viewable.

Table 5: CM and DX Code Grid Column Heading and Descriptions

COLUMN DESCRIPTION

No. Displays the serial number.

Indicators Displays code impact symbols

ICD10 Enter and view the code

Description Displays the description for corresponding code

POA Enter and view the POA value

Table 6: PCS, PX and CPT/HCPCS Code Grid Column Heading and Descriptions

COLUMN DESCRIPTION

No. Displays the serial number

Indicators Displays code impact symbols

ICD10 Enter and view the code

Description Displays the description for corresponding code

EP Enter the episode number

Date Enter the episode date

Time Enter the procedure time

Provider Enter the procedure provider information

HCPCS Displays the HCPCS code

M1 - M4 Enter HCPCS modifiers or select them from the drop-down list NOTE: You can enter up to 4 modifiers by clicking the + icon.

Unit Enter the quantity for the HCPCS code

Rev Enter the revenue code for the HCPCS code

Charge Displays the charge for the HCPCS code

APC/ASC (ICD-9/ICD-10) Enter the APC or ASC that relates to the HCPCS code

37 Clintegrity Coding/Abstracting User Guide

COLUMN DESCRIPTION

PSI Displays the Payment Status Indicator

Rate Displays the rate at which the reimbursement is calculated

% Displays the percentage paid for APC

Reimb Displays the total reimbursement paid for APC

ASC Fee Displays the ASC fee amount

EAPG Displays the EAPG value

Type Displays the type of reimbursement

Cat Displays the category of reimbursement

Rate Displays the reimbursement rate

AddOn Enter the add on information

Condition Codes Select relevant condition codes from the drop-down list NOTE:

 Same Condition Codes apply to both ICD-9 and ICD-10 code versions.

 Up to 7 condition codes can be entered by clicking the + icon.

 You can press ENTER key to move focus to next condition code.

 CPT/HCPCS - The CPT/HCPCS Code Grids includes HCPCS and CPT codes. You can switch between HCPCS and CPT by clicking the drop-down arrow in the Search for Code field and selecting the desired option. The HCPCS Code Gird defaults to CPT. The APC column in CPT/ HCPCS has the APC, ASC, and EAPG as the drop-down options:

NOTE:

 The EPAG option displayed in the drop-down depends on the type of Payor selected.

 The reimbursement options display based on APC/ASC/EAPG selection from the drop-down list under  the CPT/HCPCS code grid.

 9 and 10 next to APC/ASC/EAPG displays only when you have ICD-10 license. (example: APC9, APC10, and so on)

NOTE: The Episode Link column displays next to the Provider column only if the Enable Abstracting Episode Link on Procedural Info setting is selected under Coding/Abstracting\Setup\User Preferences\Display Settings.

Code Icons and Text in Code Grid

 The code icons will be available for each grid separately. In addition to all the icons, APC Calculate, APC Details, Calculate ASC icons, and RVRBS icons are displayed on the CPT/ HCPCS icons panel only.

 All the codes appearing in the Code Grid will be left-aligned.

38 Chapter 2 Getting Started

Code Packages

 Click the Code Packages icon to view the Code Packages section on the left side and the Code Grids vertically stacked to the right.

 Click the button on the Code Grids section to hide the Code Packages section and view the single view display.

 Click the Close button in the Code Packages section to close the Code Packages section.

Figure 87: Code Packages and Code Grids shown

 When codes are selected from a Code Package for a hidden grid, the hidden Code Grid is shown.

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Figure 88: Selected a CPT/HCPCS Code Package

Figure 89: CPT/HCPCS Code Grid in view and selected codes displayed

Code Connections

 Click the Code connections icon from any Code Grid to view the Code Connections pop-up window.

 When a code for a hidden Code Grid is selected from the Code Connections pop-up window, the hidden Code Grid is shown in view.

 When a code is added through the Crosswalk link on the Context menu, the focus sets to the row of the corresponding Code Grid.

Code Edits

 When an edit for a hidden Code Grid appears, click on the edit to show the hidden Code Grid.

 The cursor will focus on the row of the Code Grid which requires an edit.

 To re-hide the shown Code Grid, click the button.

40 Chapter 3 Coding User Interface

Chapter 3  Coding User Interface

This section explains various components of the application interface of Clintegrity and conventions used, so you can understand these common terms and techniques.

 Navigating With Icons (see page 41)

 Using Online Help (see page 45)

Navigating With Icons Icons are navigation tools that move you from one area or task in Clintegrity to another. There are two types of icons, general Clintegrity icons, and Coding specific icons.

 Clintegrity Icons, which you see in the upper right-hand corner of the page. Clintegrity icons is accessible from any module.

 Coding - Specific Icons, which run across the top of the page.

Clintegrity Icons

Figure 90: Clintegrity Icons

Table 7: Clintegrity Icons and Descriptions

ICON DESCRIPTION

Click to return to the main Clintegrity page.

Click to create bookmarks.

Click to launch the Clintegrity Online Help. See Using Online Help.

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ICON DESCRIPTION

Click to view the following options:

 Coding/Abstracting Setup

 CDI Setup

 Compliance Setup

 Record Management Setup

 EDM Setup

 File Manager Setup

 Admin

Click to sign out of the Clintegrity application.

42 Chapter 3 Coding User Interface

Coding - Specific Icons

Generic icons display here

Codes panel icons display here

Figure 91: Coding Screen

Table 8: Coding Specific Icons and Descriptions

ICON DESCRIPTION

Generic Icons

Click to view patient details

Click to close patient details NOTE: The icon displays only when you view the patient details

Click to edit patient details

Click to when editing of patient details is done

Click to launch the Documents window under EDM

Click to launch the Forms window (see Creating and Printing Forms)

Click to launch the Notes window

Click to launch the History window

Click to launch the Code Book.

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ICON DESCRIPTION

Click to launch the References window.

Click to launch the CDI window

Codes Panel Icons

Click to shuffle all codes

Click to view the Copy Codes window

Click to view the Code Packages window (see Add Code Packages to the Codelist)

Click to view the Code Connections window

Click to view the 3M™ APR DRG Detail window

Click to view the Alternate PDx/PCM window

Click to view the DRG Pro window

Click to view the APC Detail window (see View APC Detail)

Click to get codes from the Compliance module

Click to link to Abstracting NOTE: This icon displays when preference is on and there is an Episode screen in Abstracting and after the EP is entered in EP field.

Click to calculate the APCs

Click to calculate the ASCs

Click to view the Code Builder window (see Add Codes From the Code Builder)

Click to group all codes for 3M™ or APC related groupers

Click to view the RBRVS values in a pop-up.

44 Chapter 3 Coding User Interface

Using Online Help When you are working in Clintegrity, you can access the online help files for information about and instructions on using the various Clintegrity modules.

The online help files for Clintegrity contain the same information as is in the user guides.

How to ...

 Access Online Help (see page 45)

 Navigate in Online Help (see page 46)

 Search in Online Help (see page 46)

 Exit Online Help (see page 46)

Access Online Help While you are working in Clintegrity, you can see the Help icon at the top right of each screen.

Help icon

Figure 92: Online Help Icon

1. Click the Help icon to view a pop-up list of the available Clintegrity help files.

2. Click the application name that you need help with (for example Clintegrity Chart Locator) to open the online help file.

Figure 93: Clintegrity Online Help File Links

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Navigate in Online Help This graphic shows you some buttons and icons you can click to move around in online help:

Click to go Click to go to Click to show to Search Click to print the contents Index the content

Table of Contents.

Figure 94: Navigation in Online Help

Search in Online Help You can find information in online help by navigating through the chapters. To look for any specific information you can type the specific term in the index or in the Search field.

1. To search using the index, do the following:

a. Click the Index tab to see the list of index items.

b. Click a specific word to move to the location in the book where the word occurs.

c. Click on the topic to view it in the right pane.

2. To search for a specific term, using the Search field, do the following:

a. Click the Search tab to access the term search field.

b. Enter the term you want to find (for example, deficiency or check out). c. Click Go. All topics with your search terms are listed on the left side of the screen in order of relevance.

d. Click any of the terms to open its page.

3. To return the Table of Contents to the left pane of the screen, click the Contents tab at the top of the left pane.

Exit Online Help Click the ( ) button to exit online help.

46 Chapter 4 Coding Setup

Chapter 4  Coding Setup

Once you are the System Administrator, working with other technical resources and and the NUANCE implementation team at your facility, ensure that the required data is available in Coding and Abstracting. Once the required data is available, the HIM/Medical Records department will make some key decisions about how data is handled. They will set up user and facility preferences, custom coding variables, and encounter field properties, which are explained in this chapter.

Setting Coding Preferences

How to ...

 Set Up User Preferences (see page 47)

 Set Up Facility Preferences (see page 53)

 Determining Shuffle Settings (see page 63)

 Set Abstracting Screen Order (see page 68)

 Set Up Global Preferences (see page 69)

Set Up User Preferences Depending upon your applications configuration, you need to set up User Preferences before you can start using the application. User preferences are global, which means that they apply to all the facilities within an enterprise.

Setting up User Preferences may include the following:

 Coding – Configure Search Defaults, Display Settings and E&M Calculator Settings.

 Abstracting – Configure which tabs appear in encounters by default.

 ICD-10 – Configure Search Defaults and Display Settings sections.

47 Clintegrity Coding/Abstracting User Guide

Follow these steps to set up the user preferences:

1. Select Coding/Abstracting\Setup\User Preferences to open the User Preferences page.

Smart Search for CM Smart Search for PCS Codebook Codebook

Display CLU Processed checkbox

Figure 95: User Preferences Page

2. Select the option for the type of search that should be performed in each code book. For ICD-9 Books and HCPCS Books, the search types are:

Table 9: ICD-9 and HCPCS Books Search Types and Descriptions

SEARCH TYPE DESCRIPTION

Standard Search Returns results from the index of the code book you are searching. If you search for more than one term, you receive results for the two terms together. Standard Search is the system default setting.

Find All-Index Returns results based on the terms searched in the form of hyperlinks. Clicking the hyperlink displays Index view.

Find All-Tabular Returns results from the table of the code book you are searching.

Smart Search Returns results from the index of the code book you are searching. It provides suggestions as you type, filtering the possible matches found in the codebook.

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For CM Codebook and PCS Codebook, the search types are:

Table 10: ICD-10 CM and PCS Codebooks Search Types and Descriptions

SEARCH TYPE DESCRIPTION

Find All-Index Returns results based on the terms searched in the form of hyperlinks. Clicking the hyperlink displays Index view.

Find All-Tabular Returns results from the table of the code book you are searching.

Standard Search Returns results from the index of the code book you are searching. If you search for more than one term, you receive results for the two terms together. NOTE: Standard Search is the system default setting.

Smart Search Returns results from the index of the code book you are searching. It provides suggestions as you type, filtering the possible matches found in the codebook.

Table Returns results based on each character of the code that is selected by you. This search type is only available for the ICD-10 PCS search.

3. To display search results based on selection in the View Encounters Search Default drop-down list, retain default values in all other search fields.

4. Select an appropriate option from View Encounters Search Default drop-down list.

Table 11: Display Settings options

FIELD DESCRIPTION

Automatically view Code Check this if you want to automatically view Code Connection when a code Connection when a code is added. is added

Display ICD-9 Tabular Check this if you want Includes and Excludes information displayed in the Instructional Notes code’s entry in the tabular.

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FIELD DESCRIPTION

Automatically view Check this if you want to see a ICD-9 code’s Smartip in a pop-up window Smartip when ICD-9 while you are coding. code is added (Other)

Automatically view Check this if you want to see a ICD-10 code’s Smartip in a pop-up window Smartip when ICD-10 while you are coding. code is added (Other) NOTE: By default, this setting is selected. In the checked state, these settings work in the following pattern:

 When a code is entered manually, smartips are not automatically displayed.

 When code search is initiated from Code Grid, All Smartips are displayed, if the All Smartips button is selected, or Advanced Smartips are displayed if Advanced Smartips Only button is selected.

 When code search is initiated from above the Code Grid, All Smartips are displayed if the All Smartips button is selected or Advanced Smartips are displayed if Advanced Smartips Only button is selected. By deselecting these options, no smartips are displayed when a code is entered or searched using above methods.

Automatically view Select this option to see smartips for ICD-9 code in a pop-up window while Smartip when ICD-9 you are entering an ICD-9 code to the Code Grid. code is added (Direct Entry)

Automatically view Select this option to see smartips for ICD-10 code in a pop-up window Smartip when ICD-10 while you are entering an ICD-10 code to the Code Grid. code is added (Direct Entry) By selecting these options, when an ICD-9/ICD-10 code is entered directly in the Code Grid, the Smartips pop-up for All or Advanced Smartips is displayed. By deselecting these options, the Smartips pop-up is not displayed when a code is entered directly into the Code Grid.

View ICD-9 Smartips Choose the type of ICD-9 Smartips to view.

 All Smartips

 Advanced Smartips Only

Smartips created by users are advanced smartips.

View ICD-10 Smartips Choose the type of ICD-10 Smartips to view.

 All Smartips

 Advanced Smartips Only

Smartips created by users are advanced smartips.

Display ICD-9 Procedure Select this if you want to show the Px grid on the Procedural Information for Outpatient page for outpatient encounters.

Display ICD-10 PCS for Select this if you want to show the PCS grid on both Coding and Outpatient Procedural Information page for outpatient encounters.

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FIELD DESCRIPTION

Display CPT/HCPCS for Select this if you want to show the HCPCS grid on the Coding page for Inpatient inpatient encounters. Users can collapse and expand all grids while in an encounter, regardless of the User Preferences settings. The default settings are restored when the encounter is closed.

Display CLU Processed Select this to display the encounter list of CLU Processed encounters.

Display CLU codes All Suggested, Rejected, Replaced codes are displayed in sorted manner. sorted alphanumeric (Suggested, Rejected, Replaced)

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5. Add or change the Visit Type/EDM default document folders and E&M calculator settings.

a. If you also use Electronic Document Management, select EDM Default Document Folders for patient type and for documents. Click the Add link to add another patient type.

b. Select defaults from the drop-down lists in the E&M calculator settings section. These options can be overridden when coding the encounter.

Table 12: E&M Calculator Options and Descriptions

OPTION DESCRIPTION

Visit Type Category Select the category for which you want to configure defaults.

Visit Type SubCategory Select the sub-category to configure.

Guidelines Select the set of guidelines to use for the category.

c. Set the Default Tab preferences for each facility. These settings determine the page that appears by default for Abstracting encounters.

Table 13: Default Tab Preferences and Descriptions

FIELD DESCRIPTION

Inpatient Select the first page to appear by default on inpatient encounters. NOTE: By default, this setting is hidden.

Outpatient Select the first page to appear by default on outpatient encounters. NOTE: By default, this setting is hidden.

Physician Select the first page to appear by default on physician encounters.

6. Select the Display suggested PCS Codes on Outpatient Encounters setting under the CAC Settings section. The PCS Code Grid with all suggested PCS codes in the Codes Panel for an outpatient encounter is displayed on the Coding screen.

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Set Up Facility Preferences

1. Select Coding/Abstracting\Setup\Facility Preferences to access the Facility Preferences page (which is shown here in sections).

Figure 96: Facility Preferences Screen

2. From the Facility drop-down, select the facility for which you want to select preferences.

3. Set the RBRVS reimbursement settings. The RBRVS Facility checkbox controls the reimbursement calculation to use for the facility or non-facility Practice Expense (PE).

53 Clintegrity Coding/Abstracting User Guide

 If you select the box, the facility-based PE factor is used for the calculation.

 If you do not select the box, the non-facility based PE factor is used. NOTE: To generate physician reimbursements correctly you also need to set the Fee Schedule Area field in Admin\Facility. Refer to the Facility section in the System Administration Guide.

 You can look-up these RBRVS reimbursement values, in a pop-up, if you have HCPCS/CPT codes in the code grid, while creating an Inpatient or Outpatient encounter.

Figure 97: RBRVS ReiHCPCS\mbursement Values

 If there are no CPT/HCPCS codes in the CPT/HCPCS code grid, the RBRVS icon on the CPT/HCPCS code grid is disabled.

Figure 98: RBRVS Icon Disabled NOTE: In Inpatient and Outpatient encounters, RBRVS icon is displayed only for users with Physician coding license. 4. In the Interface Settings section, indicate how Coding and Abstracting interact with the Clintegrity database and Compliance.

54 Chapter 4 Coding Setup

a. Set the basic interface settings:

Table 14: Basic Interface Settings and Descriptions

SETTING DESCRIPTION

Retrieve Encounter Note file Select if you want notes on encounters transferred into the from Clintegrity Database Clintegrity database via an interface retrieved from the database. NOTE: By default, this setting is hidden.

Store Encounters in the Check if encounters should be stored in the Clintegrity database Clintegrity Database during the coding task and again during the compliance task. If (concurrent database) this is not checked, encounters are not be stored concurrently in Coding. NOTE: By default, this setting is hidden.

b. Set the inpatient and outpatient Compliance integration options. If you do not want to send an encounter from Coding or Abstracting to Compliance, do not select any options.

Table 15: Compliance Inpatient and Outpatient Integration Options and Descriptions

SETTING DESCRIPTION

Auto- Populate Check if you want encounters passed from Coding to Compliance. Compliance checking is performed and selection sets are created in Compliance. You can then review and correct selections in Compliance.

Visit Type If you choose either Self-Review or Auto-populate for IP or OP Compliance selection integration, a list of available visit types opens. Choose which visit types you want assigned to the review type.

 If you assign no visit types to a review, the review is not done.

 A visit type can be applied to only one review type.

Self-Review Check if you want to code encounters in Coding and then review them in real-time in Compliance for validation selections for billing and for reporting purposes. NOTE: With self-review, you cannot exit the system through Compliance. After you sign-in through Coding, you must also log out from Coding.

NOTE: These settings are displayed only if you have the Compliance license. NOTE: For Auto-Populate and Self-Review, upon saving an encounter (IP or OP), when there are no changes in Compliance, a coder no longer sees any edits in the edits drop-down after returning to Coding.

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c. For both the HL7 Inbound and HL7 Outbound settings, check the options appropriate for your facility.

Table 16: HL7 Inbound and HL7 Outbound Settings Options and Descriptions

SETTING DESCRIPTION

Allow updates on If selected, when the coding status is Complete: Coding completed  If compliance status is Released, no bill hold is created. records  If compliance status is Held then a bill hold is created. (Held status includes encounters set to Pending.)

 If compliance status is Reviewed, coding validation and rule settings for completed encounters run on billed codes. If this option is not checked, when Coding status is Complete, codes are sent to billing. No bill holds are generated based on the status in Compliance.

Do not allow If selected, completed encounters, regardless of compliance status, are not updates on updated. Complete Encounters

Send Coding If checked, encounters with a Coding status of Complete are sent outbound. Complete

Send All All encounters are sent outbound.

Update Coding When checked, HL7 outbound messages are sent when the from Compliance Compliance encounter is released. If held due to edits triggering, an outbound message is not sent until the encounter is saved as Reviewed in Compliance. Any coding changes made to the encounter in Compliance before it is saved as Reviewed are updated to the Coding encounter once the Compliance encounter is saved as Reviewed. To use this setting, Auto-Populate needs to be selected for at least one visit type for Inpatient Compliance Integration or Outpatient Compliance Integration.

NOTE: These settings are displayed only if you have the HL7 license.

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5. Indicate how data in certain fields should be entered, validated, allowed or displayed by checking or clearing the checkboxes.

Figure 99: Field Settings Screen

57 Clintegrity Coding/Abstracting User Guide

Table 17: Field Settings and Descriptions

SETTING DESCRIPTION

Require Birth Weight, Select this if you want to override the grouper’s rule on birth weight. regardless of grouper  This applies to inpatient encounters. To make it apply to outpatient version other than APDRG, encounters as well, also check the box Assign DRG to Outpatient Tricare and APR DRG Encounter. groupers  Birth weight is required for all encounters in the prenatal period grouped by APDRG, APRDRG, and Tricare groupers; do not check this box if those two groupers are sufficient for your facility’s needs. For further information, see About Required Fields and Read-Only Fields on page 87. NOTE: Prenatal period = 0 - 28 days of birth.

Validate Physician Name Select this if the physician name should be validated during coding.

Auto-populate Present on Select this if you want to set the default POA value for a given facility Admission with value [X] that can be updated based on the requirements. NOTE: From this setting, if the CLU suggests a POA, then the suggested POA will be displayed instead of the POA value.

Display Reason for Visit Select this to show the reason for visit fields for outpatient encounters.

Display Condition Codes & Select this if condition and revenue codes should be displayed on the Revenue Codes encounter. NOTE: By default, this setting is hidden and selected.

Display Diagnosis Link for Select this if the diagnosis link column should be displayed on the Outpatient Encounters outpatient encounter.

Display Hierarchical Select this to display the Hierarchical Condition Categories (HC/HR) Condition Categories indicators in the CM code grid for inpatient encounters. For outpatient encounters, to display the Hierarchical Condition Categories (HC/HR) indicators in the CM code grid, select both Display Hierarchical Condition Categories and Assign DRG to Outpatient Encounters.

Allow Non-hospital Select this if non-hospital approved modifiers can be used on approved modifiers encounters.

Default Outpatient Select this to keep the outpatient admit and discharge date the same Encounter Discharge Date while coding. to Admit Date

Default procedure date to Select this if the admit date should be displayed as the procedure date admit date (inpatient) on the inpatient encounter. NOTE: By default, this setting is hidden and selected.

Default procedure date to Select this if the admit date should be displayed as the procedure date admit date (outpatient) on the outpatient encounter. NOTE: By default, this setting is hidden and selected.

Assign DRG to Outpatient Select this if you want DRGs assigned to both Inpatient and outpatient Encounters encounters.

58 Chapter 4 Coding Setup

SETTING DESCRIPTION

Display Codes Appropriate Select this if you want to map the current CMS codes back to the to Grouper codes valid for the grouper (so those codes display on the screen and are sent through the interface). NOTE: By default, this setting is hidden and selected.

Enable Poisoning Code in Select this if you want the poison codes to be hyperlinks. If the poison Table of Drugs and codes are hyperlinks, the coder can click the code to go to its index Chemicals entry (without generating an E-code). NOTE: By default, this setting is hidden and selected.

Update Episode Select this if you want to automatically update all episodes having the Information same episode number. NOTE: When changes are made, you are asked if all providers are to be updated before the change is made; Units of service, revenue codes, and total charges will not be changed.

Display Diagnosis Present Select this if the Diagnosis Assigned at Admission field should be on Admission displayed during coding. NOTE: By default, this setting is hidden.

Enable Abstracting Check this if you want to enable the Episode link to copy the specific Episode Link on code from the Procedural Info screen to the Abstracting Episode Procedural Info screen.

Enable Abstracting HCPCS Check this if you want to navigate directly from the code grid to the Link on Physician Coding Episode or HCPCS screen for data entry.

59 Clintegrity Coding/Abstracting User Guide

6. Select coding shuffle (both ICD-9 and ICD-10), encounter coding, form printing, and LTCH grouper settings.

Figure 100: Coding Shuffle Settings Page

a. For the Coding Shuffle Settings: ICD-9, select the appropriate options to indicate which and how many codes of each type should be shuffled when considering reimbursement. Note the following.  If the Shuffle all MCC/CC diagnosis codes option is selected, all Major Complication and Comorbidity and Complication and Comorbidity codes are shuffled, regardless of the number of Px or Dx codes to be shuffled. If the option is not checked, codes are shuffled if the DRG would be different if codes outside this shuffle count preference would lead to a different DRG.  If the Shuffle all ICD procedure codes box is checked, all procedure codes are shuffled, regardless of the number of Px codes to be shuffled. If the box is not checked, codes are shuffled if the DRG would be different if codes outside this shuffle count preference would lead to a different DRG.  The value as of 1/1/2011 of Diagnosis and Procedure codes that can be shuffled is 25. The client can set this field to any value that is needed by their facility. Date sensitive settings are added to the Coding Shuffle Settings.  The Coding Shuffle Settings: ICD-9 fields are: Number of Diagnosis Codes to be shuffled (must be <=400) on or before 12/31/2010: Number of Procedure Codes to be shuffled (must be <=400) on or before 12/31/2010: Number of Diagnosis Codes to be shuffled (must be <=400) on or after 1/1/2011: Number of Procedure Codes to be shuffled (must be <=400) on or after 1/1/2011:

60 Chapter 4 Coding Setup

 If the Shuffle All APR DRG SOI/ROM Codes (Diagnosis and Procedure Codes) is checked, the SOI/ROM codes are shuffled, regardless of the number of Px or Dx codes to be shuffled. If the box is not checked, the codes outside the shuffle count will be shuffled.  If the Auto-Shuffle ICD-9 codes box is checked, the ICD-9 codes are automatically shuffled.

NOTE: All the codes are shuffled only when both the Auto Shuffle all ICD -9 codes (automatically shuffles all codes) option and the Shuffle all APR DRG SOI / ROM codes (Procedure and Diagnostics Codes) option are selected.

 Number of Diagnosis Codes to be shuffled (must <= 400) – This applies only to Dx codes.  Number of Procedure Codes to be shuffled (must <=400) – This applies only to Px codes.

See Determining Shuffle Settings on page 63 for further explanation of Coding Shuffle Settings.

b. For the Coding Shuffle Settings: ICD-10, check the appropriate checkboxes to indicate which and how many codes of each type should be shuffled when considering reimbursement. Note the following.  If the Self Review option is checked under Coding/Abstracting\Setup\Facility Preferences\Interface Settings and manual shuffle is on for ICD-10 encounters coming from Compliance, the Shuffle ICD-10 Codes link is enabled based on the codes added or deleted in Compliance. Manual shuffle is on when the following settings are checked: Shuffle all ICD-10 MCC/CC diagnosis codes Shuffle all ICD-10 procedure codes  If the Auto-Populate option is checked under Coding/Abstracting\Setup\Facility Preferences\Interface Settings and auto shuffle is on for ICD-10 encounters coming from Compliance, shuffle occurs automatically when you click the Get Codes from Compliance icon in the Coding screen. Auto shuffle is on when the following settings are checked: Shuffle all ICD-10 MCC/CC diagnosis codes Shuffle all ICD-10 procedure codes Auto-Shuffle ICD-10 Codes (automatically shuffles all codes).  Number of Diagnosis Codes to be shuffled (must <= 400) – This applies only to CM codes.  Number of Procedure Codes to be shuffled (must <=400) – This applies only to PCS codes.

NOTE:

 All the codes are shuffled when both the Shuffle all ICD-10 MCC/CC diagnosis codes and Shuffle all ICD-10 procedure codes settings are selected.

 The Shuffle all ICD-10 APR DRG SOI / ROM codes (CM and PCS Codes) setting is grayed out and is displayed only if you have the APR license.

 In case of dual coding, you can shuffle the codes in the ICD-9 and ICD-10 Coding screens as per the settings made individually for ICD-9 and ICD-10 code shuffle.

See Determining Shuffle Settings for further explanation of Coding Shuffle Settings.

7. Set the Encounter Coding Settings.

61 Clintegrity Coding/Abstracting User Guide

a. For Maximum Number of Codes, indicate the number of Px, Dx and HCPCS codes that are allowed on an encounter. If an encounter exceeds this number of codes, then the Coding encounter cannot be saved.

NOTE: By default, the maximum number of codes is set to 25 for accepted and added codes.

b. For Episode Date can be set, indicate how many days the episode date can precede the admit date for inpatient encounters.

NOTE: This setting is applicable only for 3 days.

c. For Outpatient ICD-10 Start Date (From Date Default), indicate date from which ICD-10 Coding and Procedural Information screens start to display in Outpatient Encounter.

d. For Outpatient ICD-10 Criteria, indicate the criteria for Outpatient Encounter to meet in order to display ICD-10 Coding and Procedural Information screens.

NOTE:

 The Outpatient encounters setup criteria are the values for Outpatient ICD-10 Start Date (From Date default) and Outpatient ICD-10 Criteria (default).

 Please contact Client Support so that the appropriate changes can be made to the HL7 Interface portion of this feature.

8. For Form Printing Settings section, you can select one default form to automatically print when an encounter is saved as Complete.  Select the form you want printed from the drop-down list.  Select the option for type of encounter for which you want the form printed – inpatient, outpatient, or physician.  Enter how many forms you want to be printed. You can print up to 99.  Select the visit types for which to print the form.

NOTE:  ICD-10 Inpatient Billing Form, ICD-10 Outpatient Billing Form, ICD-10 Abstracting Summary, ICD-10 Coding Summary Forms, and ICD-10 Physician Attestation Forms are available in the drop-down list for the Default form selected option.  You can select only one type of form (and for only one encounter type) for automatic printing. You can manually print other forms while working in the application.

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Determining Shuffle Settings Use this table to help you determine which shuffle settings to set for your facility.

Table 18: Coding Shuffle Settings and Results

OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Coding Shuffle Settings: ICD-9

Shuffle all If you do not want  When you click the Shuffle ICD-9 codes link, all codes flagged as MCC/CC automatic shuffling. being MCC/CCs are sequenced below the principal diagnosis diagnosis regardless of their impact on the DRG assignment. codes Checking this box enables the Shuffle  If you do not initiate a code shuffle, the following message ICD-9 codes link on the pops up when you save (either as Complete or Incomplete), bottom left of the regardless of impact on the DRG assignment. Coding page.

Figure 101: Codes Shuffle Warning Window - Example I Click one of the following buttons to continue.  Auto Shuffle – Click to shuffle all MCC/CCs that immediately follow the principal diagnosis.  Manual Shuffle – Click to close the pop-up, return to the encounter, and make shuffling changes yourself.  Save and Close – Click to save the encounter with the codes in the sequence you coded them.

Shuffle all ICD If you do not want  When you click the Shuffle ICD-9 codes link, all codes flagged as procedure automatic shuffling. being ICDs are sequenced below the principal procedures codes regardless of their impact on the DRG assignment. Checking this box enables the Shuffle  If you do not initiate a code shuffle, the following message ICD-9 codes link on the pops up when you save (either as Complete or Incomplete), bottom left of the regardless of impact on the DRG assignment. Coding page.

Figure 102: Codes Shuffle warning Window - Example II Click one of the following buttons to continue.  Auto Shuffle – Click to shuffle all ICDs that immediately follow the principal diagnosis.  Manual Shuffle – Click to close the pop-up, return to the encounter, and make shuffling changes yourself.  Save and Close – Click to save the encounter with the codes in the sequence you coded them.

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OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Both If you check both...  The user can enter ICD-9 procedure codes in the grid. Shuffle All ICD  The system shuffles all procedure codes on the shuffle logic. Procedure codes  The system auto-shuffles codes up using the value set in the following settings: and  Number of Procedure Codes to be shuffled (must be Auto-Shuffle <=400) on or before 12/31/2010: ICD-9 Codes (automatically  Number of Procedure Codes to be shuffled (must be shuffles all <=400) on or after 1/1/2011: codes)

Auto-Shuffle To allow ICD-9-CM Because this preference sets Clintegrity to shuffle codes ICD-9 Codes diagnosis or automatically: (automatically procedure codes to  The Shuffle ICD-9 codes link on the Coding page is disabled; you shuffles all move automatically cannot use it. codes) into the N positions that impact DRG  On save, you do not receive a message to shuffle codes. assignment (where N is either the value set in the Number of Diagnosis Codes to be shuffled or Number of Procedure Codes to be shuffled).

Both If you check both...  All diagnosis codes are automatically shuffled under the Shuffle all principal diagnosis regardless of impact on DRG assignment. MCC/CC  All codes impacting the DRG assignment are automatically diagnosis moved to the top N diagnosis or procedure positions (where N codes is either the value set in the Number of Diagnosis Codes to be and shuffled or Number of Procedure Codes to be shuffled). Auto-Shuffle  The Shuffle ICD-9 codes link on the Coding page is disabled; you ICD-9 Codes cannot use it. (automatically  On save, you do not receive a message to shuffle codes. shuffles all codes)

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OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Neither If you leave both  No automatic shuffling is done for you. Shuffle all unchecked...  The Shuffle ICD-9 codes link is enabled. Click it to shuffle all MCC/CC codes flagged as being MCC/CCs that impacts DRG diagnosis assignment to sequence them below the principal diagnosis. codes  If you have not initiated a code shuffle, when you save the nor encounter the following message pops up if codes need to be Auto-Shuffle re-sequenced for DRG assignment. ICD-9 Codes (automatically shuffles all codes)

Figure 103: Codes Shuffle Warning Window - Example III Click one of the following buttons to continue.  Auto Shuffle – Click to shuffle codes that impact DRG assignment into the first nine positions for Dx codes and first six positions for Px codes.  Manual Shuffle – Click to close the pop-up, return to the encounter, and make shuffling changes yourself.  Save and Close – Click to save the encounter with the codes in the sequence you coded them. You only receive this message if codes need to be re-sequenced for DRG assignment.

Shuffle All APR Shuffle ICD-9- codes link a. When user clicks on the Shuffle ICD-9- codes link: DRG SOI/ROM is enabled All codes flagged as SOI/ROM are sequenced below the PDx codes code shuffle warning will regardless of their impact on DRG. APR DRG Reordering rules (Diagnosis and are applied. Procedure appear only when hit Codes) save without initiating b. When user attempts to save the encounter without clicking on is checked a code shuffle the Shuffle ICD-9- codes link: System displays code shuffling warning when you save (either as complete or incomplete) with following options to choose: i. Auto shuffle: Shuffles all SOI/ROM codes and places them right under the principal diagnosis code. APR DRG Reordering rules are applied. ii. Manual Shuffle: Allows user to manually shuffle codes based on facility guidelines. No reordering rules are enforced. iii. Save and Close: Saves the codes in the order they were entered. No shuffling is performed.

Auto Shuffle All Shuffle ICD-9- codes link System will automatically shuffles all ICD-9 Dx or Px codes such ICD-9 codes is is disabled that they will move into the N positions that impact the DRG checked assignment.

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OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Both Shuffle ICD-9- codes link The Number of X Codes to be shuffled settings are not used by APR Shuffle All APR is disabled shuffle. APR shuffle looks at all codes and shuffles them based DRG SOI/ROM on the APR shuffling logic. codes (Diagnosis and Procedure Codes) and Auto-Shuffle all ICD-9 codes (automatically shuffles all codes) is checked

Neither Shuffle ICD-9- codes link a. When user clicks on the Shuffle ICD-9- codes link: Shuffle All APR is enabled All codes flagged as SOI/ROM are sequenced below the PDx. DRG SOI/ROM APR DRG Reordering rules are applied. codes code shuffle warning will (Diagnosis and appear only when hit b. When user attempts to save the encounter without clicking on Procedure save without initiating the Shuffle ICD-9- codes link: a code shuffle Codes) System displays code shuffling warning when you save (either nor as complete or incomplete) with following options to choose: i. Auto shuffle: All codes flagged as SOI/ROM are sequenced Auto-Shuffle All as outlined in the APR DRG Reordering Rules. APR DRG ICD-9-codes Reordering rules are applied. (automatically shuffles all ii. Manual Shuffle: Allows user to manually shuffle codes based codes) on facility guidelines. No reordering rules are enforced. iii. Save and Close: Saves the codes in the order they were is checked entered. No shuffling is performed.

Coding Shuffle Settings: ICD-10

Shuffle All If you do not want  When you click the Shuffle ICD-10 codes link, all codes flagged ICD-10 MCC/CC automatic shuffling. as being ICD-10 MCC/CCs are sequenced below the principal diagnosis diagnosis regardless of their impact on the DRG assignment. codes Checking this box enables the Shuffle ICD-10 codes link on the bottom left of the Coding page.

Shuffle all If you do not want  When you click the Shuffle ICD-10 codes link, all codes flagged ICD-10 automatic shuffling. as being ICDs are sequenced below the principal procedures procedure regardless of their impact on the DRG assignment. codes Checking this box enables the Shuffle ICD-10 codes link on the bottom left of the Coding page.

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OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Both If you check both...  The user can enter ICD-10 procedure codes in the grid. Shuffle All  The system shuffles all procedure codes on the shuffle logic. ICD-10 Procedure  The system auto shuffles all the codes irrespective of the codes number mentioned. and Auto-Shuffle ICD-10 Codes (automatically shuffles all codes)

Auto-Shuffle To allow ICD-10-CM Because this preference sets Clintegrity to shuffle codes ICD-10 Codes diagnosis or automatically: (automatically procedure codes to  The Shuffle ICD-10 codes link on the Coding page is disabled; shuffles all move automatically you cannot use it. codes) into the N positions that impact DRG assignment (where N is either the value set in the Number of Diagnosis Codes to be shuffled or Number of Procedure Codes to be shuffled).

Both If you check both...  All diagnosis codes are automatically shuffled under the Shuffle All principal diagnosis regardless of impact on DRG assignment. ICD-10 MCC/CC  All codes impacting the DRG assignment are automatically diagnosis moved to the top N diagnosis or procedure positions. codes  The Shuffle ICD-10 codes link on the Coding page is disabled; and you cannot use it. Auto-Shuffle  On save, you do not receive a message to shuffle codes. ICD-10 Codes (automatically shuffles all codes)

Neither If you leave both  No automatic shuffling is done for you. Shuffle All unchecked...  The Shuffle ICD-10 codes link is enabled. Click it to shuffle all ICD-10 MCC/CC codes flagged as being ICD-10 MCC/CCs that impacts DRG diagnosis assignment to sequence them below the principal diagnosis. codes nor Auto-Shuffle ICD-10 Codes (automatically shuffles all codes)

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OPTION CHECK THIS BOX.... RESULTS, WHEN WORKING IN CODING

Shuffle All The Shuffle all ICD-10 APR DRG SOI/ROM Codes (CM and PCS Codes) option is enabled. ICD-10 APR DRG SOI/ROM Codes (CM and PCS Codes) Checked

Auto Shuffle All Shuffle ICD-10- codes System will automatically shuffle all ICD-10 CM or PCS codes ICD-10 codes is link is enabled such that they will move into the N positions that impact the DRG checked assignment.

Set Abstracting Screen Order If you use Abstracting, you can set preferences for the order in which screens appear.

1. Select Coding/Abstracting\Setup\Abstracting Screen Order.

Figure 104: Abstracting Screen Order Window

2. From the drop-down list, select the facility for which you are setting screen order.

3. In Inpatient and Outpatient columns, only one Coding screen and all other Abstracting screens are displayed.

4. In the Physician column, specify the order in which you want to access screens for the physician type.

5. Click the Save button to save your changes. Your selections then appear in the numerical order you specified.

6. If you want to return to the default settings, click Restore Defaults and then click Save.

NOTE: You can save and exit from the encounter with the Abstracting screen, when the Shuffle functionality is enabled.

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Set Up Global Preferences You can set up global preferences that apply to all facilities in the enterprise. Global preference determine how encounters relate to each other across modules. Global preferences also determine what type of identifying information to use to find encounters for a patient when copying a patient’s codes from one encounter to another.

1. Select Coding/Abstracting\Global Preferences to display the Global Preferences page.

Figure 105: Global Preferences Screen

2. Select an appropriate option to choose how physician service and facility encounters should be related.

 MRN – MRNs must match.

 Name, DOB – First name, last name, middle initial, and date of birth must match.

3. Click the appropriate option if you want to allow inpatient or outpatient encounters to share the same account number with physician encounters.

4. When you finish adding or changing this preference, click Save.

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Importing and Exporting Information

How to ...

 Import Coding System Information (see page 70)

 Export Coding System Information (see page 71)

Import Coding System Information You can import several kinds of system data to Coding/Abstracting. This can save your time when setting up an enterprise with multiple facilities.

1. Select Coding/Abstracting\Setup\item-to-import, where the item-to-import is Synonyms, Smartips, Alternate Descriptions, or Code Packages. (For this example, synonyms are being imported.)

Figure 106: Synonyms Screen for Item-to-Import

2. Click Import to open the Synonym: Import window.

Figure 107: Synonym Import Window

3. Select the Facility for which you want to import the information.

4. Select an import file from the List of import file names in the drop-down list.

 You are warned that the imported data overwrites existing data.

 Samples of import files are in the Docs\QCOD\samples Files folder located in the software files.

5. Click Import. The import results are displayed when the import is complete.

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Export Coding System Information You can export several kinds of system data from Coding. This can save you time when setting up an enterprise with multiple facilities.

1. Select Coding/Abstracting\Setup\item to export (where the item is Synonyms, Smartips, Alternate Descriptions, or Code Packages). For this example, synonyms are being exported. Exporting the rest of the data types is done the same way.

Figure 108: Synonyms Screen for Item-to Export

2. Click Export to open the Synonym: Export window.

Figure 109: Synonyms Export Window

NOTE: When the drop-down icon is shown, you can type the first letter of the term you want to locate. The system locates the first term with the specified letter. If you select the same letter again, it should take you to the next item starting with that letter. You can also use the ARROW keys to move within the list to select a term. If you select the same letter again, it should take you to the next item in the list starting with the same letter.

3. Select the facility for which you want to export the setup information.

4. Specify an Export File name.

5. Click Export. The export results are displayed when the export is complete.

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Adding Coding Variables You can create the following types of coding variables.

Table 19: Coding Variables and Descriptions

CODING VARIABLE DESCRIPTION

Synonyms Synonyms are abbreviations that represent common terms and are used in an index search to save time while coding.

Smartips Smartips are specific to the code being reviewed. They can be used to add notes and tips that the coder can view when coding.

Code Packages Code packages are groupings of codes that are commonly used together. These elements can either be required or suggested.

Alternate Descriptions Alternate descriptions are created as another method of recognizing and coding commonly used diagnosis (Dx) codes.

How to ...

 Create or Change Synonyms (see page 73)

 Create or Change Smartips (see page 77)

 Create or Change Code Packages (see page 81)

 Create or Change Alternate Descriptions (see page 83)

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Create or Change Synonyms Synonyms are also known as abbreviations. They represent commonly used terms that are recognized in an index search to save time while coding. If you do not have permission to create system-wide synonyms, you can create synonyms that can only be used by you.

1. Select Coding/Abstracting\Setup\Synonyms to access the list view of the Synonyms page.

Figure 110: Setup Synonyms Page

NOTE: In the Usage column, A stands for Administrator, U for User, and G for Group. The group name appears on the form view page for the specific Synonym.

2. To search for a synonym, select a criterion from the drop-down list, enter a search value in the text field, and click Go.

3. To import synonyms, click Import. See Import Coding System Information on page 70 for instructions.

4. To export synonyms, click Export. See Export Coding System Information on page 71 for instructions.

5. To delete a synonym, select the synonym and click Delete.

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6. To add a new synonym or edit an existing one.

a. Click Add New to add a new synonym, or click the Synonym link of an existing synonym to edit it. The form view of the Synonyms page appears.

Figure 111: Synonyms Form View Screen

b. Fill in the fields, some of which are described below. Fields marked with an asterisk (*) require data.

Table 20: Synonym Specification Fields and Descriptions

FIELD DESCRIPTION

*Synonym Enter the Synonym name, maximum 16 characters. NOTE: If you are changing synonym information, the information in this field cannot be edited.

*Code Type Select the type of code you want to add a synonym to from the following options available:

 CPT

 E Code

 HCPCS

 CM

 PCS

 Dx

 Px

*Linking Code or Select whether this synonym represents a term or a code, and enter that Term code or term’s value.

*Usage Select whether the synonym should be available for group use, or limited to the user creating the synonym.

Groups Select the groups to which the synonym is available.

c. Click the Print icon to print either the synonym or a blank synonym form. ( )

d. Click Save to save your changes, or click Cancel to discard changes.

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View Synonyms

1. Select Coding/Abstracting\Setup\Synonyms to access the list view of the Synonyms page.

2. To search for a Synonym, select a Search criterion from the drop-down list and enter a search value in the text field. The following options are available in the drop-down list:

Table 21: Synonym Search Types and Descriptions

SEARCH TYPE DESCRIPTION

Synonym Searches based on synonym information

Index Term Searches based on index entries for any of the words

Last Modified Date Searches based on last modified date

Author Searches based on author name

Dx Code Searches based on Dx code

E Code Searches based on E code

Px Code Searches based on Px code

CPT Code Searches based on CPT code

HCPCS Code Searches based on HCPCS code

CM Code Searches based on CM code

PCS Code Searches based on PCS code

Figure 112: Synonyms page

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3. Press ENTER or click Go. The system displays the Synonyms based on your search entries.

Select Search Enter search text and criterion click Go

Figure 113: Search Synonyms Screen

4. To print a report of all the synonyms in the system, click the Print icon.

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Create or Change Smartips Smartips are specific to the code being reviewed. They can be used to add notes and tips that the coder can view when coding. If you do not have permission to create system-wide smartips, you can create smartips that can only be used by you.

1. Select Coding/Abstracting\Setup\Smartips to access the list view of the Smartips page.

Figure 114: Smartips List View Screen

NOTE: In the Usage column, A stands for Administrator, U for User and G for Group. The group name appears on the form view page for the specific smartip.

2. To search for a smartip, select criterion from the drop-down list and click Go.

3. To import smartips, click Import. See Import Coding System Information on page 70 for instructions.

4. To export smartips, click Export. See Export Coding System Information on page 71 for instructions.

5. To preview or print a report of all the smartips in the system, click the Preview or Printer icon, respectively. ( ) ( )

NOTE:

 The Print background colors and images option of Internet Explorer 8.0 in Tools\Internet Options\Advanced\Printing, now need to be selected for printing Q line symbol in the smartips window.

 Printing a report of Smartips is based on the size of your XML file. Some files are large and might require large amounts of paper.

6. To delete a smartip, check the box at the end of its line and click Delete.

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7. To add a new smartip or edit an existing one:

a. Click Add New to add a new smartip or click the Code link of an existing smartip to edit it. The form view of the Smartips page appears.

Figure 115: Smartips Form View Screen

b. Fill in the fields with the following information. Fields with an asterisk (*) require an entry.

Table 22: Smartips Specification Fields and Descriptions

FIELD DESCRIPTION

*Code Type Select the type of code for the smartip, for example, HCPCS or Dx code.

*Linking Code(s) Enter the range of codes to which the smartip applies.

 Enter decimal points appropriately in the code. For example, enter 952.10 not 95210.  Click Add to add more lines for additional code ranges.

Source Enter the source of the smartip.

*Smartip Enter the text of the smartip.

*Usage Choose whether usage should be available for a group, or limited to the user creating the smartip.

Groups Select the groups to which the smartip is available.

8. Click Save to save your changes, or click Cancel to discard changes.

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View Smartips

1. Select Coding/Abstracting\Setup\Smartips to access the list view of the Smartips page.

2. To search for a smartip, select a Search criterion from the drop-down list and enter a search value in the text field.

a. The following options are available in the drop-down list:

Table 23: Smartips Search Types and Descriptions

SEARCH TYPE DESCRIPTION

Code Type Searches based on code type for synonym

Dx Code Searches based on Dx code entered

E Code Searches based on E code entered

Px Code Searches based on Px code entered

CPT Code Searches based on CPT code entered

HCPCS Code Searches based on HCPCS code entered

CM Code Searches based on CM code entered

PCS Code Searches based on PCS code entered

Group Searches based on group entered

Smartip Searches based on smartip

Author Searches based on author name entered

Figure 116: Smartips Setup Page

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3. Press ENTER or click Go. The system displays the Smartips based on your search entries.

Figure 117: Setup Smartips Screen

4. Click the Preview or Printer icon to preview or print the report of all smartips in the systems, respectively. ( ) ( ) NOTE: The Smartips can also be seen for the respective partial 7 Character ICD-10 CM codes.

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Create or Change Code Packages Code packages are groupings of codes that are commonly used together. These elements can either be required or suggested. You must have permission to create and change code packages.

NOTE: You cannot enter duplicate codes into Code Packages.

1. Select Coding/Abstracting\Setup\Code Packages to access the list view of the Code Packages page.

Figure 118: Code Packages List View Screen

2. To search for a code package, select search criterion from the Search drop-down list, enter a search value in the text field, and click Go.

3. To import code packages, click Import. See Import Coding System Information on page 70 for instructions.

4. To export code packages, click Export. See Export Coding System Information on page 71 for instructions.

5. To print a report of all the code packages in the system, click the Printer icon. ( )

6. To delete a code package, check the checkbox at the end of its line and click Delete.

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7. To add or edit a code package:

a. Click Add New to add a new code package or click the Code link of an existing code package to edit it. The form view of the Code Packages page appears.

Figure 119: Code Package Form View Screen

b. Fill in the fields with the following information. Fields with an asterisk (*) require an entry.

Table 24: Code Package Specification Fields and Descriptions

FIELD DESCRIPTION

*Code Enter the name of the code package, maximum 16 characters. Package Name NOTE: If you are changing code package information, the information in this field cannot be edited.

Comments Enter any comments about the code package.

*Groups Select the groups to which the code package is available.

Code Version Select the code version, either ICD-9 or ICD-10, of the code package.

 If you select ICD-9 Code Version, Dx, Px, and E Code options are displayed whereas CM and PCS options are not displayed in the Code Type drop-down.

 If you select ICD-10 Code version, CM and PCS options are displayed whereas Dx, Px, and E Code options are not displayed in the Code Type drop-down.

 CPT/HCPCS options are enabled for both ICD-9 and ICD-10 Code versions.

 Code Packages with only CPT/HCPCS options are displayed under Coding/Abstracting\Code Packages based on the Code Version (ICD-9/ICD-10) selected.

*Code Type Select the type of code to add to the code package. For example select HCPCS or Dx code.

*Code Enter the code to add to the code package.

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c. Click Add Code. The code is added under the heading of its type of code, at the bottom of the screen.

d. Add additional codes until the code package is complete.

e. When you have completed the code package, you can specify whether or not the codes are required or suggested, for inclusion in the code package by clicking the appropriate checkbox in each section. (Required [ ], Suggested [ ])

f. You can also perform any of these actions.  To remove a code from the code package, click the Remove link next to the code.  To remove all the codes from the code package, click Remove All Codes.  To print the code package or a blank Code Package form, click the Printer icon. ( )

g. Click Save to save your changes or click Cancel to discard changes.

Create or Change Alternate Descriptions Alternate descriptions are created as another method of recognizing and coding commonly used diagnosis (Dx) codes. Alternate descriptions should be archived prior to upgrading the Clintegrity system. See Export Coding System Information on page 71 for instructions. You must have permission to create and change Alternate descriptions.

1. Select Coding/Abstracting\Setup\Alternate Descriptions to access the list view of the Alternate Descriptions page.

Search Drop-down

Figure 120: Alternate Descriptions List View Screen

2. To search for an alternate description, select search criterion from the Search drop-down list, enter a search value in the text field, and click Go.

3. To import alternate descriptions, click Import. See Import Coding System Information on page 70 for instructions.

4. To export alternate descriptions, click Export. See Export Coding System Information on page 71 for instructions.

5. To print a report of all the alternate descriptions in the system, click the Printer icon. ( )

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6. To delete an alternate description, click the checkbox at the end of its line and click Delete.

7. To add or edit an alternate description:

a. Click Add New to add an alternate description, or click the Code Type link for an alternate description to edit it. The form view of the Alternate Descriptions page appears.

Code Type Drop-down

Figure 121: Alternate Descriptions Form View Screen

b. Fill in the fields with the following information. Fields with an asterisk (*) require an entry.

Table 25: Alternate Descriptions Specification Fields and Descriptions

FIELD DESCRIPTION

*Code Type Select the type of code, for example, HCPCS, Dx, or CM code.

*Code Enter the code for which you are creating the alternate description.

Code Description Enter a description of the code.

Attending Physician ID Enter the physician for whom the alternate description is being created. If it is for global use, leave this field blank.

*Alternate Description Enter the alternate description for the code.

*Facilities Select the facilities to which the alternate description is available.

c. To print the alternate description or a blank Alternate Descriptions form, click the Printer icon. ( )

d. Click Save to save your changes, or click Cancel to discard the changes.

NOTE:

 The maximum length of the Alternate Descriptions for ICD-10 Code Types (CM and PCS) is 256 characters.

 You can edit/update the code description only using Alternate Descriptions.

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Setting Up Custom Statuses You can create custom statuses in which to place Complete and Incomplete encounters. For instance, you can create a status of Lab to designate encounters that are incomplete pending Lab reports or a status of R for encounters that have been Reviewed for Compliance. When searching for encounters, you can perform searches by status.

How to ...

Create a Custom Status You can create a custom status for both Coding and Abstracting. The steps given here specifically mention the coding status, but you follow the same steps to create abstracting statuses; just select the Abstracting Status option rather than the Coding Status option.

1. Click Coding\Setup\Coding Status to open the list of current custom statuses.

The steps to create a custom status are the same, whether you want to create a coding status or an abstracting status.

Figure 122: Coding Status Screen

2. To search for a coding status, select a search criterion from the Search drop-down list, enter a search value in the text field, and click Go. To return to the complete list of statuses, click Show All.

3. To activate or deactivate a coding status, click in the Active checkbox for the coding status. (Statuses with a check are active and statuses without a check are inactive.) Then click Update.

4. To add or edit a coding status:

NOTE: The Complete and Incomp coding statuses cannot be edited.

a. Click Add New to create a new custom status, or click the Status ID for an existing status to edit it.

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b. On the Coding Status form, fill in the fields with the following information. Fields with an asterisk (*) require an entry.

Figure 123: Coding Status Form View Screen

Table 26: Coding Status Fields and Descriptions

FIELD DESCRIPTION

*Enterprise ID Enter the name of the coding status. This name appears in the Coding status drop-down list in the encounter.

Description Enter a description of the coding status.

*Coding Status Select the status for the encounter, either Complete or Incomplete. This is the actual status. Your custom ID, such as Holding for Lab Work, is the reason for the status.

*Facilities Select the facilities to which the custom status is available.

c. Click Save to save your changes, or click Cancel to discard the changes.

When you next work in an encounter, the custom statuses you have set up for that facility appear in the Coding status drop-down list.

Figure 124: Coding Status Drop-Down List (Without Abstracting License)

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NOTE: When no Abstracting license, the Save button will save the encounter as Complete by default.

Figure 125: Coding Status Drop-Down List (With Abstracting License)

About Required Fields and Read-Only Fields You can specifying whether fields are required or read-only on records. This section explains how to set up these fields and provides particular information about two fields—the Principal Dx and Birth Weight fields (see below).

 Principal Dx field – The Principal Dx field is a system-required field. An encounter must have a principal diagnosis code (a valid ICD-9 diagnosis code) before you can save it with a coding status of Complete. When you save an encounter that does not have a Principal Dx code:

 If saving the encounter as Complete, you receive a error message and cannot save the encounter. This is a system-wide setting.

 If saving the encounter as Incomplete, you can save it. However, you can specify that required fields must be filled in even before saving an encounter with a coding status of Incomplete. See Copy Coding Configuration to Multiple Facilities Settings on page 102, Configure OP Rules Settings on page 106 and Configure Physician Rules Settings on page 120.

NOTE: In the Codes panel, if there are codes from 2nd row and no Principal diagnosis code is assigned, then an error message displays when you save as Complete or Incomplete.

 Birth Weight field – The Birth Weight field is mandatory for all encounters in prenatal period only when you select:

 The Birth Weight setting under Coding/Abstracting\Setup\Field Properties

 The Require Birth Weight, regardless of grouper version other than APDRG, Tricare and APR DRG groupers setting under Coding/Abstracting\Setup\Facility Preferences

NOTE: If the Birth Weight field is blank while saving the encounter with Save , then:

 Edit is triggered when the settings are On.

 Edit is not triggered when the settings are Off.

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How to ...

Set Up Required and Read-Only Fields

1. Select Coding/Abstracting\Setup\Field Properties.

Figure 126: Field Properties Set Up Screen

2. Select the facility to which these field properties apply from the drop-down list.

3. Indicate the patient type to which these field properties apply by clicking the radio button next to the appropriate type.

4. Check the box Only apply Read-Only fields on Interlink interface records if you only want read-only fields applied to Interlink encounters during an open Interlink session.

5. Indicate whether a field is required or read-only by clicking the checkbox in the appropriate column. Your institution’s required and read-only fields depend upon its particular requirements.

NOTE:

 If a checkbox is greyed-out (even if checked), you cannot change the attribute of that field, it is required by the system.

 The ICD-10 fields display only if you have the ICD-10 Coding license.

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Setting Compliance Rules If your Coding or Abstracting system is integrated with Compliance, you need to set up the compliance rules that are used when the encounter goes from Coding to Compliance.

How to ...

 Configure Compliance IP Selection Rules (see page 89)

 Configure Compliance IP Selection Rules ICD-10 (see page 93)

 Configure Compliance OP Selection Rules (see page 96)

 Configure Compliance OP Selection Rules ICD-10 (see page 99)

Configure Compliance IP Selection Rules Before you can begin working in Compliance, you or your system administrator must configure the standard selection rules that are mandatory. Follow these steps to configure the rules before running the selection process.

1. Select Coding/Abstracting\Setup\Compliance IP Selection Rules.

Figure 127: Compliance IP Selection Rules Screen

2. Select the facility to which these rules apply from the Facility drop-down list.

3. Select the visit types for which these rules apply from the Visit Types drop-down list.

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4. Select the copy from facility for which these rules apply from the Copy from Facility drop-down list.

NOTE: The list of facilities will include all facilities, even if you do not have permission for a facility. This will allow set up across an enterprise.

5. Select custom rules if you want to apply them when selecting encounters for review.

See the Compliance User Guide for instructions on creating custom rules.

6. Check the boxes for the criteria you want used during encounter selection.

See IP Selection Rule Criteria on page 91 for more information on the rules.

7. When you finish setting your preferences, click Save.

NOTE: Copying from one facility to another does not change the set up of the facility you are copying from.

8. Click the Preview icon to review the edit settings that have been set up.

9. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

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IP Selection Rule Criteria This table describes the standard inpatient compliance rules used for Coding and Compliance integration.

Table 27: IP Selection Rule Criteria and Descriptions

CRITERIA RULE TYPE DESCRIPTION

Select Encounters for all possible Selects all the checkboxes on the page. Upon saving, the checkbox problems appears unchecked to allow set up preferences to be used again.

Regulatory Edits Selects all checkboxes in this expandable list.

MCE The Medicare Code Editor (MCE) detects and reports errors in the ICD-9 CM coding claims data to help identify possible errors in coding based on ICD-9 Coding System codes for payment under the mandated Inpatient Prospective Payment System (IPPS).

Inpatient OIG Target OIG is designed to use logic that will either increase or decrease reimbursement or is revenue neutral. Generally based on the history of selected DRGs by the OIG and RAC during the compliance audits. DRG Transfer rule can be set here.

Transfer DRG Transfer of MS DRG payments are reduced when:

 The beneficiary’s LOS is at least one day less than the geometric mean LOS for the DRG.

 And, the beneficiary is transferred to another hospital covered by the acute IPPS or, for certain MS-DRGs, discharged to a post-acute setting. The following post-acute care settings and discharge disposition codes are included in the transfer policy:

 03 SNF

 05 Cancer hospitals and Children’s hospitals

 06 Home health care when the beneficiary receives clinically related care that begins within three days after the hospital stay

 62 Inpatient rehabilitation facilities; including inpatient rehab units of a hospital

 63 Long-term care hospitals

 65 Psychiatric facilities; Psychiatric DP units located in an acute care hospital

Revenue Edits Selects all checkboxes in this expandable list. NOTE: A new category, ICD-10 CC/MCC Edits, has been added to the Revenue Edits, which can be selected or deselected, as required.

Inpatient Revenue IREV is designed to use logic that would potentially increase reimbursement by suggesting code logic to obtain an appropriate higher weighted MSDRG. DRG patient attributes such as complications or comorbidities (CC/ MCC), different principal diagnoses, additional procedures are some of the general content of the messages for suggested DRG changes.

Data Quality Edits Selects all checkboxes in this expandable list.

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CRITERIA RULE TYPE DESCRIPTION

Relational Code Edits These edits were created in accordance with Uniform Hospital Discharge Data Set (UHDDS) standards, International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS), according to conventions, instructions, and guidelines.

Inpatient Data Quality IQUAL is designed to use logic that will either increase but usually decreases estimated reimbursement or is revenue neutral and in many cases just prompts for DRG verification/validation.

ICD9 Relational Edits Checks entered codes for illogical, erroneous, incompatible, required combinations, correct sequencing (both diagnosis and procedure).

ICD9 ECode Edits Prompts you to add External Cause of Injury, Place of Occurrence, Activity, and Status, as applicable.

QCheck Edits Category Prompts you to look for a related or more specific code by providing appropriate corresponding diagnosis or procedure codes for selection, if applicable.

APR-DRG Edits All Patient Refined (APR) DRG compliance edits are grouper specific Category and are based on APR-DRG logic to validate or suggest diagnosis and procedure selection based on coded APR-DRG in accordance with Official Coding Guidelines, conventions, and instructions.

PSI Edits Category Patient Safety Indicator (PSI) edits were created in accordance with the Agency for Healthcare Research and Quality. These edits are a set of diagnoses and procedures providing information on potential hospital complications and adverse events following surgeries, procedures, and childbirth.

IQI Edits Category Inpatient Quality Initiatives were created in accordance with the Agency of Healthcare Research and Quality. These edits are a set of diagnoses, procedures, or DRGs selecting accounts for all the Mortality Measures with discharge disposition = 20.

Ignore Charge Criteria Check this box if you would like the selection logic to ignore Clintegrity charge criteria as part of the selection process.

Ignore Length of Stay Criteria Check this box if you would like the selection logic to ignore Clintegrity LOS criteria as part of the selection process.

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Configure Compliance IP Selection Rules ICD-10 Before you can begin working in Compliance, you or your system administrator must configure the standard selection rules that are mandatory. Follow these steps to configure the rules before running the selection process.

1. Select Coding/Abstracting\Setup\Compliance IP Selection Rules ICD-10.

Figure 128: Compliance IP Selection Rules ICD-10 Screen

2. Select the facility to which these rules apply from the Facility drop-down list.

3. Select the visit types for which these rules apply from the Visit Types drop-down list.

4. Select the copy from facility for which these rules apply from the Copy from Facility drop-down list.

NOTE: The list of facilities will include all facilities, even if you do not have permission for a facility. This will allow set up across an enterprise.

5. Select custom rules if you want to apply them when selecting encounters for review.

See the Compliance User Guide for instructions on creating custom rules.

6. Check the boxes for the criteria you want used during encounter selection.

See IP Selection Rule Criteria on page 91 for more information on the rules.

7. When you finish setting your preferences, click Save.

NOTE: Copying from one facility to another does not change the set up of the facility you are copying from.

8. Click the Preview icon to review the edit settings that have been set up.

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9. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

ICD-10 IP Selection Rule Criteria This table describes the standard inpatient compliance rules used for Coding and Compliance integration.

Table 28: ICD-10 IP Selection Rule Criteria and Descriptions

CRITERIA RULE TYPE DESCRIPTION

Select Encounters for all possible Selects all the checkboxes on the page. Upon saving, the checkbox problems appears unchecked to allow set up preferences to be used again.

Regulatory Edits Selects all checkboxes in this expandable list.

ICD 10 MCE The Medicare Code Editor (MCE) detects and reports errors in the coding claims data. All inpatient encounters subject to Prospective Payment Systems (PPS) are reviewed for these edits. When this item is expanded, the individual MCE edits are displayed. The checkbox next to each edit can be checked or unchecked for inclusion in the rule. (Public Domain Edits)

ICD-10 Inpatient OIG Edits based on selected DRGs by the OIG and RAC during Target compliance audits. There is no official targeted DRG list as they use the broad catch all phrase in the Work Plan to say that they watch for any pattern of aberrant coding practices generally to mean fraudulent upcoding. OIG is designed similar to IQUAL and IREV to use logic that will either increase or decrease reimbursement or is revenue neutral.

Revenue Edits Selects all checkboxes in this expandable list.

ICD-10 Inpatient IREV is designed to use logic that would potentially increase Revenue reimbursement by suggesting code logic to obtain an appropriate higher weighted MSDRG. DRG patient attributes such as complications or comorbidities (CC/ MCC), different principal diagnoses, additional procedures are some of the general content of the messages for suggested DRG changes.

Data Quality Edits Selects all checkboxes in this expandable list.

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CRITERIA RULE TYPE DESCRIPTION

ICD 10 Relational Code These edits were created in accordance with Uniform Hospital Edits Discharge Data Set (UHDDS) standards, International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10 CM) and ICD-10 PCS (Procedural Coding System), according to conventions, instructions, and official coding guidelines.

ICD-10 APR-DRG Edits All Patient Refined (APR) DRG compliance edits are grouper Category specific and are based on APR-DRG logic to validate or suggest diagnosis and procedure selection based on coded APR-DRG in accordance with Official Coding Guidelines, conventions, and instructions.

ICD-10 PSI Edits Patient Safety Indicator (PSI) edits were created in accordance with Category the Agency for Healthcare Research and Quality. These edits are a set of diagnoses and procedures providing information on potential hospital complications and adverse events following surgeries, procedures, and childbirth.

IQI Edits Category Inpatient Quality Initiatives were created in accordance with the Agency of Healthcare Research and Quality. These edits are a set of diagnoses, procedures, or DRGs selecting accounts for all the Mortality Measures with discharge disposition = 20.

ICD-10 QCheck Edits Prompts you to look for a related or more specific code by providing Category appropriate corresponding ICD-10 CM and PCS codes for selection, if applicable.

Ignore Charge Criteria Check this box if you would like the selection logic to ignore Clintegrity charge criteria as part of the selection process.

Ignore Length of Stay Criteria Check this box if you would like the selection logic to ignore Clintegrity LOS criteria as part of the selection process.

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Configure Compliance OP Selection Rules

1. Select Coding/Abstracting\Setup\Compliance OP Selection Rules.

Figure 129: Compliance OP Selection Rules Screen

2. Select the facility to which these rules apply from the Facility drop-down list.

3. Select the visit types for which these rules apply from the Visit Type drop-down list.

4. Select the copy from facility for which these rules apply from the Copy from Facility drop-down list.

NOTE: The list of facilities will include all facilities, even if you do not have permission for a facility. This will allow set up across an enterprise.

5. Select custom rules if you want to apply any when selecting encounters for review.

See the Compliance User Guide for instructions on creating custom rules.

6. Check the boxes for the criteria you want used during encounter selection.

See OP Selection Rule Criteria on page 97 for more information on the rules.

7. When you finish setting your preferences, click Save.

NOTE: Copying from one facility to another does not change the set up of the facility you are copying from.

8. Click the Preview icon to review the edit settings that have been set up.

9. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

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OP Selection Rule Criteria This table describes the standard outpatient compliance rules used for Coding and Compliance integration.

Table 29: OP Selection Rule Criteria and Descriptions

CRITERIA RULE TYPE DESCRIPTION

Select Encounters for all Selects all the checkboxes on the page. Upon saving, the checkbox appears possible problems unchecked to allow set up preferences to be used again.

Regulatory Edits Selects all checkboxes in this expandable list.

OCE (including The Outpatient Code Editor (OCE) program edits patient data to help identify CCI) possible errors in coding based on Healthcare Common Procedure Coding System (HCPCS) codes for payment under the mandated Outpatient Prospective Payment System (OPPS).

Medically Tests claim lines for the same beneficiary, Health Care Common Procedure Unlikely Edits Code System (HCPCS) code, date of service, and billing provider against a (MUEs) criteria number of units of service. The MUEs auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims containing lines with units of service that exceed an MUE criteria.

EAPG These edits are based on the 3M™ guidelines. Edits used will be based on the EAPG schedule selected. Different schedule types cannot be used simultaneously. NOTE: This edit displays only if you have the EAPG license.

TRICARE OCE These edits are the TRICARE OCE established by TRICARE. All outpatient (including CCI) encounters subject to TRICARE OCE are screened for these edits. When this item is expanded, all the TRICARE OCE edits are shown. The TRICARE OCE edits can be selected or not selected based on the active selection rules being run between Coding and Compliance. NOTE: This edit displays only if you have the TRICARE license.

Nuance OCE Proprietary coding edits for invalid patient From and Through date (encounter additions and discharge).

Medical Review National Coverage Decisions (NCD) and Local Coverage Decisions (LCD) for Policies the facilities’ fiscal intermediary/carrier are applied here. The encounter will be screened against the NCD first and then against the appropriate LCD. These tables are updated on a quarterly basis. However, monthly LCD content updates are available for download via Web deployment.

Part B Medical Necessity edits can be applied on all outpatient encounters in Facility Coding and OP Compliance. However, the setup for Medical Necessity editing is done both in Admin\System Configuration\Facility and Admin\System Configuration\Payor.

Data Quality Edits Selects all checkboxes in this expandable list.

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CRITERIA RULE TYPE DESCRIPTION

Relational Code These edits were created in accordance with Uniform Hospital Discharge Data Edits Set (UHDDS) standards, International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS), according to conventions, instructions, and guidelines.

Dx/HCPCS These Outpatient Compliance edits compare the diagnosis with the HCPCS Linkage procedure code to verify accuracy.

HCPCS Protocol These Outpatient Compliance edits prompt for a more specific or related procedure (that is open versus closed, bilateral, multiple procedures, and so on).

Modifier Code Modifier edits prompt you to add more specific information to a CPT code that Edits affects the amount the provider or facility will be reimbursed.

ICD-9 Relational Checks entered codes for illogical, erroneous, incompatible, required Edits combinations, correct sequencing (both diagnosis and procedure).

CPT Relational Using CPT instructional notes, checks entered codes for illogical, erroneous, Edits incompatible, required combinations, correct sequencing, supplemental component code reporting.

ICD9 ECode Prompts you to add External Cause of Injury, Place of Occurrence, Activity, Edits and Status, as applicable.

QCheck Edits Prompts you to look for a related or more specific code by providing Category appropriate corresponding diagnosis or procedure codes for selection, if applicable.

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Configure Compliance OP Selection Rules ICD-10

1. Select Coding/Abstracting\Setup\Compliance OP Selection Rules ICD-10.

Figure 130: Compliance OP Selection Rules ICD-10 Screen

2. Select the facility to which these rules apply from the Facility drop-down list.

3. Select the visit types for which these rules apply from the Visit Type drop-down list.

4. Select the copy from facility for which these rules apply from the Copy from Facility drop-down list.

NOTE: The list of facilities will include all facilities, even if you do not have permission for a facility. This will allow set up across an enterprise.

5. Select custom rules if you want to apply any when selecting encounters for review.

See the Compliance User Guide for instructions on creating custom rules.

6. Check the boxes for the criteria you want used during encounter selection.

See OP Selection Rule Criteria on page 97 for more information on the rules.

7. When you finish setting your preferences, click Save.

NOTE: Copying from one facility to another does not change the set up of the facility you are copying from.

8. Click the Preview icon to review the edit settings that have been set up.

9. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

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ICD-10 OP Selection Rule Criteria This table describes the standard outpatient compliance rules used for Coding and Compliance integration.

Table 30: ICD-10 OP Selection Rule Criteria and Descriptions

CRITERIA RULE TYPE DESCRIPTION

Select Encounters for all Selects all the checkboxes on the page. Upon saving, the checkbox appears possible problems unchecked to allow set up preferences to be used again.

Regulatory Edits Selects all checkboxes in this expandable list.

ICD 10 OCE These edits are the Outpatient Code Edits (OCEs) established by CMS. All (including CCI) outpatient encounters subject to Outpatient Prospective Payment (OPPS) are screened for these edits. When this term is expanded, all the OCE edits are shown. The check box next to each edit can be checked or unchecked for inclusion in the rule. (Public Domain Edits).

ICD 10 Medically Tests claim lines for the same beneficiary, Health Care Common Procedure Unlikely Edits Code System (HCPCS) code, date of service, and billing provider against a criteria number of units of service. The MUEs auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims containing lines with units of service that exceed an MUE criteria.

ICD 10 Nuance Proprietary coding edits for invalid patient From and Through date (encounter OCE additions and discharge).

ICD 10 Medical The encounter is screened against the National Coverage Decisions (NCD) Review Policies first and then against the appropriate Local Coverage Decisions (LCD). These tables are updated on a quarterly basis. Twice monthly, LCD content updates are available for download via Web deployment. Part A or Part B Medical Necessity edits can be applied to all outpatient encounters in Facility Coding and OP Compliance. The set up for which set up edits to apply is done in Admin\System Configuration\Facility. The specific set up local or national edits to apply is done at the Payor level. Set up for that is done in Admin\System Configuration\Payor.

Data Quality Edits Selects all checkboxes in this expandable list.

ICD 10 Relational These edits were created in accordance with Uniform Hospital Discharge Data Code Edits Set (UHDDS) standards, International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10 CM) and ICD-10 PCS (Procedural Coding System), according to conventions, instructions, and official coding guidelines.

ICD 10 These Outpatient Compliance edits compare the diagnosis with the HCPCS Dx/HCPCS procedure code to verify accuracy. Linkage

ICD 10 HCPCS These Outpatient Compliance edits compare the protocol with the HCPCS Protocol procedure code to verify accuracy.

ICD 10 QCheck Prompts you to look for a related or more specific code by providing Edits Category appropriate corresponding ICD-10 CM or PCS codes for selection, if applicable.

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About Rule Settings When encounters are imported into or created in Coding/Abstracting, the information on the encounter is validated against certain rules. For example, rules check to see if information in required fields is missing and that the date is in the expected format. The Clintegrity system is shipped with default rules that can be changed to suit your institution’s needs.

Each rule is assigned a severity level that determines the disposition of the encounter when the validation process is complete. Rules are organized first by group and then by category. The severity level can be set at any of these levels.

Table 31: Legend Icons and Descriptions

ICON DESCRIPTION

Encounter cannot be imported or saved.

Encounter can be imported and saved, but appears on the Import Warning or Code Edit report.

Encounter can be imported and saved, and is not marked with an error or warning.

Rules are also separated by coding type and encounter status. There are rules for physician and facility encounters, and for encounters with a complete or incomplete status.

 The IP Rules Settings (Complete Encounters) are applied to encounters that are completed in the Coding/Abstracting system. This IP Rules setting has a Required Fields For Complete Encounters rule that looks into the field properties set for that particular facility. For complete encounters, there cannot be any missing fields.

 IP Rules Settings (Incomplete Encounters) are applied to encounters that are imported into Coding/Abstracting from another system or saved in the Coding/Abstracting system with a status of incomplete. This IP Rules setting has a Required Fields For Incomplete Encounters rule that looks into the field properties set for that particular facility. For incomplete encounters, rules can be set to Error, Warning, or Ignore. In addition, incomplete encounter rules also have a Missing System Required Fields rule, which checks to see if an MRN, account number, facility name, and visit type are present.

How to ...

 Copy Coding Configuration to Multiple Facilities Settings (see page 102)

 Copy Coding Configuration to Multiple Facilities Settings (see page 102)

 Configure OP Rules Settings (see page 106)

 Configure IP Rule Settings ICD-10 (see page 110)

 Configure OP Rules Settings ICD-10 (see page 116)

 Configure Physician Rules Settings (see page 120)

 Configure Physician Rules Settings ICD-10 (see page 123)

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Copy Coding Configuration to Multiple Facilities Settings

1. Go to Coding/Abstracting\Setup and select any of the following rule settings:

 IP Rule Settings (Complete Encounters)

 IP Rule Settings ICD-10 (Complete Encounters)

 IP Rule Settings (Incomplete Encounters)

 IP Rule Settings ICD-10 (Incomplete Encounters)

2. Select a facility from the Facility drop-down list from which you want to copy the configuration.

3. Click sign to expand the Copy Configuration to Multiple Facilities settings section. If All Facilities is selected from the Facility drop-down list, you can not expand the Copy Configuration to Multiple Facilities settings section.

Figure 131: Copy Coding Configuration to Multiple Facilities Settings

4. Select the facility/facilities to copy the configuration from the Copy To combo box. Use the Right-arrow button and the Left-arrow button to add or remove the selected options from the Available and Selected field.

5. Click the Save button in the Copy Configuration to Multiple Facilities settings section to save the configuration settings or click Cancel to discard the changes.

NOTE:  The Save button in the Copy Configuration to Multiple Facilities settings section can be used to save the Copy Configuration to Multiple Facilities setting only.  To save all other rule settings, click the Save button on the bottom-right corner of the setup screen.

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Configure IP Rules Settings

1. Choose to configure inpatient rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\IP Rules Settings (Incomplete Encounters) or

 Coding/Abstracting\Setup\IP Rules Settings (Complete Encounters) The IP Rules Settings (Complete Enocunters) or IP Rules Settings (Incomplete Enocunters) screen is displays.

Figure 132: IP Rules Settings Screen

2. Select the facility. (Only facilities to which you have permission are in the drop-down list.)

3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule.

For more information on the groups and categories, see Groups and Categories for IP Data Rules on page 104

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\IP Rules Settings for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date.

NOTE: The default setting for new install and upgrade is set to Error.

 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

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 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

5. Click the Preview icon to review the edit settings that have been set up.

6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

Groups and Categories for IP Data Rules This table describes the standard inpatient compliance rule groups and categories used for Coding and Compliance integration.

Table 32: IP Data Rules Groups and Descriptions

GROUP CATEGORY DESCRIPTION

Regulatory

General You can specify that encounters must have all required fields (such as Validation Principal Dx) completed before they can be saved, even for an encounter with an incomplete status. For the Required Fields for Incomplete Encounters setting, select your preferred option.

MCE The Medicare Code Editor (MCE) detects and reports errors in the ICD-9 CM coding claims data to help identify possible errors in coding based on ICD-9 Coding System codes for payment under the mandated Inpatient Prospective Payment System (IPPS).

OCE (including The Outpatient Code Editor (OCE) program edits patient data to help CCI) identify possible errors in coding based on Healthcare Common Procedure Coding System (HCPCS) codes for payment under the mandated Outpatient Prospective Payment System (OPPS).

Data Quality

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GROUP CATEGORY DESCRIPTION

Relational Code These edits were created in accordance with Uniform Hospital Discharge Edits Data Set (UHDDS) standards, International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS), according to conventions, instructions, and guidelines.

Relational Code California Hospitals are required to submit Patient Discharge Data Edits - IP semi-annually to the Office of Statewide Health Planning and OSHPD Development (OSHPD) for each discharged patient. Data reported includes: Patient demographic information and diagnostic information, ICD-9 CM diagnostic codes, DRG and MDC groupings, Treatment information, ICD-9 CM procedure codes, External Cause of Injury codes (E-codes), and total charges with expected principal source of payment.

ICD-9 Relational Checks entered codes for illogical, erroneous, incompatible, required Edits combinations, correct sequencing (both diagnosis and procedure).

ICD-9 ECode Prompts you to add External Cause of Injury, Place of Occurrence, Edits Activity, and Status, as applicable.

CPT Relational Using CPT instructional notes, checks entered codes for illogical, Edits erroneous, incompatible, required combinations, correct sequencing, supplemental component code reporting.

QCheck Edits Prompts you to look for a related or more specific code by providing Category appropriate corresponding diagnosis or procedure codes for selection, if applicable.

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Configure OP Rules Settings

1. Choose to configure inpatient rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\OP Rules Setting (Incomplete Encounters) or

 Coding/Abstracting\Setup\OP Rules Setting (Complete Encounters) The OP Rules Settings page you selected appears.

Figure 133: OP Rules Settings Page

NOTE: The Medical Necessity edits can be applied on all outpatient encounters in Facility Coding and OP Compliance. Based on the setup in Admin\System Configuration\Facility, Part B edits can be applied and viewed instead of Part A edits for outpatient encounters.

2. Select a facility. (Only those facilities to which you have permission are in this list.)

3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule:

For more information on the groups and categories, see Groups and Categories for OP Data Rules on page 108

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\OP Rules Settings for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date.

NOTE:  The default setting for new install and upgrade is set to Error.  When using the future discharge date at a warning level the Nuance OCE-2 edit should be turned off to avoid conflicting error messages.

 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

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 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

5. Click the Preview icon to review the edit settings that have been set up.

6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

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Groups and Categories for OP Data Rules This table describes the standard outpatient compliance rule groups and categories used for Coding and Compliance integration

Table 33: OP Data Rules Groups and Descriptions

GROUP CATEGORY DESCRIPTION

Regulatory

General Validation You can specify that encounters must have all required fields (such as Principal Dx) completed before they can be saved, even for an Incomplete status. For the Required Fields for Incomplete Encounters setting, select your preferred option. You can specify that encounters with invalid PCS provider must display error /warning messages or ignore error/warning messages.

OCE (including CCI) The Outpatient Code Editor (OCE) program edits patient data to help identify possible errors in coding based on Healthcare Common Procedure Coding System (HCPCS) codes for payment under the mandated Outpatient Prospective Payment System (OPPS).

Medically Unlikely Edits Tests claim lines for the same beneficiary, Health Care Common (MUEs) Procedure Code System (HCPCS) code, date of service, and billing provider against a criteria number of units of service. The MUEs auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims containing lines with units of service that exceed an MUE criteria.

EAPG These edits are based on the 3M™ guidelines. Edits used will be based on the EAPG schedule selected. Different schedule types cannot be used simultaneously. NOTE: This edit displays only if you have the EAPG license.

TRICARE OCE (including These edits are the TRICARE OCE established by TRICARE. All CCI) outpatient encounters subject to the hospital TRICARE Outpatient Prospective Payment System (OPPS) are screened for these edits. When this item is expanded, all the TRICARE OCE edits are displayed. The status of TRICARE OPPS edits cannot change from error, warning or ignore. They will always run and be set to warning. NOTE: This edit displays only if you have the TRICARE license.

Nuance OCE Addition Proprietary coding edits for invalid patient From and Through date (encounter and discharge).

Medical Review Policies The encounter is screened against the National Coverage Decisions (NCD) first and then against the appropriate Local Coverage Decisions (LCD). These tables are updated on a quarterly basis. Twice monthly, LCD content updates are available for download via Web deployment.

Part A or Part B Medical Necessity edits can be applied to all outpatient encounters in Facility Coding and OP Compliance. The set up for which set up edits to apply is done in Admin\System Configuration\Facility. The specific set up local or national edits to apply is done at the Payor level. Set up for that is done in Admin\System Configuration\Payor.

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GROUP CATEGORY DESCRIPTION

DataQuality

Relational Code Edits These edits were created in accordance with Uniform Hospital Discharge Data Set (UHDDS) standards, International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS), according to conventions, instructions, and guidelines.

Modifier Code Edits Modifier edits prompt you to add more specific information to a CPT code that affects the amount the provider or facility will be reimbursed.

ICD9 Relational Edits Checks entered codes for illogical, erroneous, incompatible, required combinations, correct sequencing (both diagnosis and procedure).

CPT Relational Edits Using CPT instructional notes, checks entered codes for illogical, erroneous, incompatible, required combinations, correct sequencing, supplemental component code reporting.

ICD9 ECode Edits Prompts you to add External Cause of Injury or Place of Occurrence E codes.

QCheck Edits Category Prompts you to look in the medical record for information supporting a related or more specific code.

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Configure IP Rule Settings ICD-10

1. Choose to configure inpatient rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\IP Rules Settings ICD-10 (complete Encounters) or

 Coding/Abstracting\Setup\IP Rules Settings ICD-10 (Incomplete Encounters) The IP Rules Settings ICD-10 (Complete Enocunters) or IP Rules Settings ICD-10 (Incomplete Enocunters) screen is displays.

Figure 134: IP Rules Settings ICD-10 Screen

2. Select the facility. (Only facilities to which you have permission are in the drop-down list.)

3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule.

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\IP Rules Settings ICD-10 for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date

NOTE: The default setting is set to Error.

 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

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5. Click the Preview icon to review the edit settings that have been set up.

6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

MCE Feature for IP Rule Settings ICD-10 The MCE feature for IP Rule Settings ICD-10 has both complete and incomplete encounters under Coding/Abstracting\Setup\IP Rule Settings ICD-10 (Complete Encounters)\Regulatory and Coding/Abstracting\Setup\IP Rule Settings ICD-10 (Incomplete Encounters)\Regulatory.

The following edits display for MCE feature under the IP Rule Settings ICD-10 setting:

Table 34: Medicare Code Edits and Descriptions

MEDICARE CODE EDITS DESCRIPTION

MCE-01 Invalid CM or PCS Codes

MCE-02 External Causes Of Morbidity Code As Principal Diagnosis

MCE-03 Duplicate of Principal CM

MCE-04 CM Code - Age Conflict

MCE-05 CM/PCS - Sex Conflict

MCE-06 Manifestation Code As Principal Diagnosis

MCE-08 Questionable Admission

MCE-09 Unacceptable Principal Diagnosis

MCE-11 Noncovered Procedure

MCE-14 Invalid Age

MCE-15 Invalid Sex

MCE-16 Invalid Discharge Status

MCE-17 Limited Coverage

MCE-18 Wrong Procedure Performed

MCE-19 Procedure inconsistent with LOS

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MCE Feature for IP Rule Settings ICD-10 (Complete Encounters) The following screen displays an MCE feature under IP Rule Settings ICD-10 (Complete Encounters) setting:

MCE Edits

Figure 135: MCE Feature for IP Rule Settings ICD-10 (Complete Encounters) Screen

MCE Feature for IP Rule Settings ICD-10 (Incomplete Encounters) The following screen displays an MCE feature under IP Rule Settings ICD-10 (Incomplete Encounters) setting:

MCE Edits

Figure 136: MCE Feature for IP Rule Settings ICD-10 (Incomplete Encounters) Screen

NOTE:

 Default setting for all the updates is Warning upon upgrade.

 In case of both an MCE edit and a General Validation edit for the same error, the General Validation edit will trigger.

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ICD10DataQuality Feature The ICD10DataQuality feature has ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits for both complete and incomplete encounters settings. The following settings display under Coding/Abstracting\Setup with ICD10DataQuality feature:

 IP Rule Settings ICD-10 (Complete Encounters)

 IP Rule Settings ICD-10 (Incomplete Encounters)

The following edits are displayed for the ICD10DataQuality feature:

 ICD-10 Relational Code Edits

 ICD-10 QCheck Edits Category

Table 35: ICD-10 Relational Code Edit and Descriptions

ICD-10 RELATIONAL DESCRIPTION CODE EDITS

icd10cm04 Principal Diagnosis Only

icd10cm07 Obstetric and Abortion Conditional Code Connection

icd10cm08 Obstetric and Abortion Mandatory Code Connection

icd10cm09 Obstetric Complications

icd10cm12 Incompatible/Illogical

icd10cm14 Hierarchical Condition Category

icd10cm20 Conditional Code Connection

icd10cm21 Mandatory Code Connection

icd10cm28 Code First Conditional

icd10cm29 Code First

icd10cm34 Cannot be Principal Diagnosis

icd10cm35 Bilateral Combination

icd10cm37 HAC (IP only)

icd10cm38 Not IP Code (IP only)

icd10cm42 Patient Diagnosis Age Variable - Under Age

icd10cm43 Patient Diagnosis Age Variable - Over Age

icd10cm52 Newborn and Perinatal Code Edits

icd10cm80 External Causes Additional Detail

icd10cm82 External Cause Status

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ICD-10 RELATIONAL DESCRIPTION CODE EDITS

icd10cm83 Activity Code

icd10cm84 External Causes of Morbidity and Place of Occurrence

icd10pcs34 Cannot be Principal Procedure

icd10pcs35 Bilateral Combination

 ICD-10 QCheck Edits Category

Figure 137: ICD 10 QCheck Edits Category

Table 36: ICD-10 QCheck Edit and Descriptions

ICD-10 QCHECK EDIT DESCRIPTION

QCheck Edits Prompts you to look for a related or more specific code by providing appropriate corresponding diagnosis or procedure codes for selection, if applicable.

QCheck ICD-9 and ICD-10 DRG The edit triggers for both inpatient and outpatient encounters only if the inconsistency ICD-9 DRG does not match with the ICD-10 DRG.

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IP Rule Settings ICD-10 (Complete Encounters) The following screen displays ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits under Coding/Abstracting\Setup\IP Rule Settings ICD-10 (Complete Encounters)\ICD10DataQuality:

Figure 138: IP Rule Settings ICD-10 (Complete Encounters) Screen

IP Rule Settings ICD-10 (Incomplete Encounters) The following screen displays ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits under Coding/Abstracting\Setup\IP Rule Settings ICD-10 (Incomplete Encounters)\ICD10DataQuality:

Figure 139: IP Rule Settings ICD-10 (Incomplete Encounters) Screen

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Configure OP Rules Settings ICD-10

1. Choose to configure outpatient rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\OP Rules Settings ICD-10 (Complete Encounters) or

 Coding/Abstracting\Setup\OP Rules Settings ICD-10 (Incomplete Encounters) The OP Rules Settings ICD-10 page you selected appears.

Figure 140: OP Rule Settings ICD-10 Screen

2. Select a facility. (Only those facilities to which you have permission are in this list.)

NOTE: The Medical Necessity edits can be applied on all outpatient encounters in Facility Coding and OP Compliance. Based on the setup in Admin\System Configuration\Facility, Part B edits can be applied and viewed instead of Part A edits for outpatient encounters.

3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule:

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\OP Rules Settings for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date.

NOTE:  The default setting for new install and upgrade is set to Error.  When using the future discharge date at a warning level the Nuance OCE-2 edit should be turned off to avoid conflicting error messages.

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 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

5. Click the Preview icon to review the edit settings that have been set up.

6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

ICD10DataQuality Feature The ICD10DataQuality feature has ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits for both complete and incomplete encounters settings. The following settings display under Coding/Abstracting\Setup with ICD10DataQuality feature:

 OP Rule Settings ICD-10 (Complete Encounters)

 OP Rule Settings ICD-10 (Incomplete Encounters)

The following edits are displayed for the ICD10DataQuality feature:

 ICD-10 Relational Code Edits

 ICD-10 QCheck Edits Category

Table 37: ICD-10 Relational Code Edit and Descriptions

ICD-10 RELATIONAL CODE EDITS DESCRIPTION

icd10cm04 Principal Diagnosis Only

icd10cm07 Obstetric and Abortion Conditional Code Connection

icd10cm08 Obstetric and Abortion Mandatory Code Connection

icd10cm09 Obstetric Complications

icd10cm12 Incompatible/Illogical

icd10cm20 Conditional Code Connection

icd10cm21 Mandatory Code Connection

icd10cm28 Code First Conditional

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ICD-10 RELATIONAL CODE EDITS DESCRIPTION

icd10cm29 Code First

icd10cm34 Cannot be Principal Diagnosis

icd10cm35 Bilateral Combination

icd10cm42 Patient Diagnosis Age Variable - Under Age

icd10cm43 Patient Diagnosis Age Variable - Over Age

icd10cm52 Newborn and Perinatal Code Edits

icd10cm80 External Causes Additional Detail

icd10cm82 External Cause Status

icd10cm83 Activity Code

icd10cm84 External Causes of Morbidity and Place of Occurrence

icd10pcs34 Cannot be Principal Procedure

icd10pcs35 Bilateral Combination

 ICD-10 QCheck Edits Category

Table 38: ICD-10 QCheck Edit and Descriptions

ICD-10 QCHECK EDIT DESCRIPTION

QCheck Edits Prompts you to look for a related or more specific code by providing appropriate corresponding diagnosis or procedure codes for selection, if applicable.

QCheck ICD-9 and ICD-10 DRG The edit triggers for both inpatient and outpatient encounters only if the inconsistency ICD-9 DRG does not match with the ICD-10 DRG.

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OP Rule Settings ICD-10 (Complete Encounters) The following screen displays ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits under Coding/Abstracting\Setup\OP Rule Settings ICD-10 (Complete Encounters)\ICD10DataQuality:

Figure 141: OP Rule Settings ICD-10 (Complete Encounters) Screen

OP Rule Settings ICD-10 (Incomplete Encounters) The following screen displays ICD-10 Relational Code Edits and ICD-10 QCheck Edits Category edits under Coding/Abstracting\Setup\OP Rule Settings ICD-10 (Incomplete Encounters)\ICD10DataQuality:

Figure 142: OP Rule Settings ICD-10 (Incomplete Encounters) Screen

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Configure Physician Rules Settings

1. Choose to configure physician rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\Physician Rules Setting (Incomplete Encounters) or

 Coding/Abstracting\Setup\Physician Rules Setting (Complete Encounters).

Figure 143: Physician Rule Settings Screen

2. Select a facility from the drop-down list. (Only those facilities to which you have permission are displayed in this list.)

3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule.

For more information on the groups and categories, see Groups and Categories for OP Data Rules on page 108

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\Physician Rules Settings for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date.

NOTE: The default setting for new install and upgrade is set to Error.

 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

5. Click the Preview icon to review the edit settings that have been set up.

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6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

Groups and Categories for Physician Rule Setting

Table 39: Physician Rule Setting Groups and Descriptions

GROUP CATEGORY DESCRIPTION

Regulatory

General Validation You can specify that encounters must have all required fields (such as Principal Dx) completed before they can be saved, even for an Incomplete status. For the Required Fields for Incomplete Encounters setting, select your preferred option (see step 3).

OCE (including CCI) The Outpatient Code Editor (OCE) program edits patient data to help identify possible errors in coding based on Healthcare Common Procedure Coding System (HCPCS) codes for payment under the mandated Outpatient Prospective Payment System (OPPS).

Medically Unlikely Edits Tests claim lines for the same beneficiary, Health Care Common (MUEs) Procedure Code System (HCPCS) code, date of service, and billing provider against a criteria number of units of service. The MUEs auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims containing lines with units of service that exceed an MUE criteria. NOTE: Units of service field accept numbers with up to three decimal points.

NCCI These National Correct Coding Initiative (NCCI) edits are established by CMS. They are also known as unbundling edits. A subset of these edits is part of the OCE editor. When this item is expanded, all the CCI edits are displayed. (Public Domain Edits)

Medical Review Policies The encounter is screened against the National Coverage Decisions (NCD) first and then against the appropriate Local Coverage Decisions (LCD). These tables are updated on a quarterly basis. However, monthly LCD content updates are available for download via Web deployment. NOTE: The NCD/LCD updates must be run by someone with administrator privileges as an SQL Server trusted connection to the database is being used for updates. Part B Medical Necessity edits can be applied on all outpatient encounters in Facility Coding and OP Compliance. However, the setup for Medical Necessity editing is still done in the Payor table.

Data Quality

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GROUP CATEGORY DESCRIPTION

Modifier Code Edits Modifier edits prompt you to add more specific information to a CPT code that affects the amount the provider or facility will be reimbursed.

ICD9 Relational Edits Checks entered codes for illogical, erroneous, incompatible, required combinations, correct sequencing (both diagnosis and procedure).

CPT Relational Edits Using CPT instructional notes, checks entered codes for illogical, erroneous, incompatible, required combinations, correct sequencing, supplemental component code reporting.

ICD9 ECode Edits Enables you to add External Cause of Injury or Place of Occurrence E codes.

QCheck Edits Category Enables you to look in the medical record for information supporting a related or more specific code.

IQI Edits Category Inpatient Quality Initiatives were created in accordance with the Agency of Healthcare Research and Quality. These edits are a set of diagnoses, procedures, or DRGs selecting accounts for all the Mortality Measures with discharge disposition = 20.

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Configure Physician Rules Settings ICD-10

1. Choose to configure physician rule settings for encounters with a complete or incomplete status by selecting:

 Coding/Abstracting\Setup\Physician Rules Settings ICD-10 (Complete Encounters). or

 Coding/Abstracting\Setup\Physician Rules Settings ICD-10 (Incomplete Encounters)

Physician Rule Settings ICD-10 (Incomplete Encounters)

Figure 144: Physician Rule Settings ICD-10 (Incomplete Encounters) Screen

Physician Rule Settings ICD-10 (Complete Encounters)

Figure 145: Physician Rule Settings ICD-10 (Complete Encounters) Screen

2. Select a facility from the drop-down list. (Only those facilities to which you have permission are displayed in this list.)

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3. You can change settings for rules at the group, category, or rule level by selecting the radio button for the action you want the system to take if an encounter triggers a rule.

For more information on the groups and categories, see Groups and Categories for OP Data Rules on page 108

 To set rules for a group, click the radio button for Error, Warning, or Ignore for the group. All of the rules in the group with a severity setting that can be modified are set to your selection. You can enable the Valid Admit/From Date edit to enter future admit dates for a new install or upgrade in Coding/Abstracting\Setup\Physician Rules Settings for both complete and incomplete encounters. The Valid Admit/From Date edit settings are enabled and you can select Error, Warning or Ignore as required and save the future admit date.

NOTE: The default setting for new install and upgrade is set to Error.

 To set the rules for a category, click the + sign for a group to expand the list and show the categories in the group. Then click the radio button for Error, Warning, or Ignore. All of the rules in the category with a severity setting that can be modified are set to your selection.

 To set a specific rule, click the + sign for a group to expand the list and show the categories in the group, and then click the + sign for a category to expand the list and show the rules in the category. Click the radio button for Error, Warning, or Ignore for the rule you want to modify.

4. When you finish setting validation preferences, click Save.

5. Click the Preview icon to review the edit settings that have been set up.

6. Click Print for the report to print the data for all the values in the Facility drop-down list.

NOTE: To Print or Preview reports, you need to have one of the following permissions in Admin\Users/Security\Manage Groups\Permissions\Coding/Abstracting:  View and Setup Reports  Schedule Reports

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Groups and Categories for Physician Rules Settings ICD-10

Table 40: Physician Rule Setting ICD-10 Group and Descriptions

GROUP CATEGORY DESCRIPTION

Regulatory Edits

ICD-10 Medical Review The encounter is screened against the National Coverage Decisions Policies (NCD) first and then against the appropriate Local Coverage Decisions (LCD). These tables are updated on a quarterly basis. However, monthly LCD content updates are available for download via Web deployment. NOTE: The NCD/LCD updates must be run by someone with administrator privileges as an SQL Server trusted connection to the database is being used for updates. Part B Medical Necessity edits can be applied on all outpatient encounters in Facility Coding and OP Compliance. However, the setup for Medical Necessity editing is still done in the Payor table.

Data Quality Edits

ICD-10 Relational Code Checks entered codes for redundant or contradictory coding and for Edits appropriate use of combination codes.

ICD-10 QCheck Edits Prompts you to look for a related or more specific code by providing Category appropriate corresponding ICD-10 CM or PCS codes for selection, if applicable.

IQI Edits Category Inpatient Quality Initiatives were created in accordance with the Agency of Healthcare Research and Quality. These edits are a set of diagnoses, procedures, or DRGs selecting accounts for all the Mortality Measures with discharge disposition = 20.

NOTE:

 Only the General Validation, MCE-01, OCE-01, and Medical Review Policies edits trigger until the PDx/PCM is assigned.

 The PDx/PCM required field edit triggers upon save when at least 1 Dx/CM code is present and no PDx/PCM is assigned.

 The PDx/PCM required field edit triggers upon save as complete when there is no PDx/PCM assigned.

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About File Layouts File layouts are used to import files into Coding and export files from Coding. The file layouts tell Coding how to read files imported from other systems and how to translate files exported to other systems. If your facility uses unique data layouts, you can create them using the File Layout setup.

How to ...

Create File Layouts

1. Select Coding/Abstracting\Setup\File Layouts to access the list view of the File Layouts page.

ICD-10 File Layouts

Figure 146: File Layout List View Screen

2. To delete a layout, check the checkbox for the layout and click Delete.

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3. To add or edit a file layout:

a. Click Add New to create a new file layout, or click the Layout Name for an existing file layout to edit it. The form view of the File Layouts page appears.

Export CM codes with decimal points option

Figure 147: File Layout Form View Screen

b. Fill in the fields in the Layout Specification area with the following information.

Table 41: File Layout Specification Fields and Descriptions

FIELD DESCRIPTION

Layout Name Enter the file layout name. It cannot contain the symbols / \ : * ? : < > | NOTE: If you are editing a file layout, this field cannot be changed.

Date Format Select the date format used in layout.

Time Format Select the time format used in layout.

Weight Select the unit of measure in which you enter weights.

Length Select the unit of measure in which you enter lengths.

Layout Type Select the layout type, for example, Delimited Ascii or XML.

Export Dx Codes with Check if you want decimal points included in exported Dx code. decimal point

Export PX codes with Check if you want decimal points included in exported Px code. decimal point

Export CM codes with Check if you want decimal points included in exported CM code. decimal point

4. Click Add to refresh the page and get the proper file layout fields.

5. For the layout type Delimited ASCII, enter the delimiter. The default is a comma.

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6. Fill in the fields at the bottom of the page. The fields available depend on the layout type choice. These are the fields you might see.

Table 42: File Layout Fields and Descriptions

FIELD DESCRIPTION

Field Enter the field name in the Clintegrity database file. The available field names can be found in the interface guide for your product. NOTE: If you are changing layout information, the information in this field cannot be edited.

Description Enter a description of field. NOTE: If you are changing layout information, the information in this field cannot be edited.

Sequence Enter the sequence of the field in the layout (Delimited ASCII or Fixed Format ASCII).

Position Enter the position of field in file (Fixed Format ASCII).

Length Enter the length of field (Fixed Format ASCII).

7. If you want to add additional lines to the layout, fill in the empty fields at the bottom of the page and click Add.

8. When you finish adding or changing the layout, do any of the following, as needed.

 Click Save to save your changes to the system.

 Click Verify to check that the field names are valid, and for the Fixed Format ASCII layout type to check that the fields do not overlap.

 Click Delete to discard your changes.

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About Custom References If Abstracting is licensed and enabled at your institution, you can use custom references. Custom references can be created two different ways using the Application Builder.

 By importing pre-defined references from the Abstracting Builder.

 By creating them from scratch.

See the Application Builder User Guide for instructions on both ways to create custom references.

Once Abstracting is deployed, existing reference tables can be changed or deactivated, archived, and unarchived, and new references can be added from Setup\Custom Reference Maintenance in Abstracting.

NOTE: To update custom references, you must have permission to change custom reference tables. See your System Administrator to gain permission.

How to ...

 Create Custom References (see page 129)

 Import Custom References (see page 131)

Create Custom References

1. Select Coding/Abstracting\Setup\Custom Reference Maintenance to open the list view of the Maintain Custom References page.

Figure 148: Custom Reference Maintenance Screen

2. To search for a custom reference, select search criteria from the Search drop-down lists, enter a search item in the text field, and click Go.

3. To deactivate a custom reference, uncheck the checkbox at the end of its line and click Update.

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4. To add or edit a custom reference:

a. Click Add New to add a custom reference or click the Name link of a custom reference to edit it. The form view of the Custom References page appears.

Figure 149: Custom References Form View Screen

NOTE: If you are editing an already created reference, the system will display the list of all the reference IDs with the corresponding facility.

b. Fill in the fields.

Table 43: Custom References Fields and Descriptions

FIELD DESCRIPTION

ID Enter the ID of reference. NOTE: If you are editing a custom reference, this field cannot be changed.

Description Enter a description of the custom reference, 40 character maximum.

Copy to All Facilities Select all facilities that uses the custom reference. Here, individual mapping values if mapped previously are replaced by new Id. The Copy to All Facilities button is enabled only if there is a value in the All Facilities Reference ID field.

Clear All Select Clear All to return to the default state.

Add dClick Ad to add new facilities.

Active The Active checkbox is checked by default.

c. When you finish adding or changing the custom reference, click Save to save your changes, or click Cancel to discard your changes.

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Import Custom References The system administrator can import custom reference values into Clintegrity after the structure of the reference has been created in the Abstracting QDesigner Dataset Builder, in a comma delimited file. Perform the import on the Clintegrity server machine.

1. Select Coding/Abstracting\Setup\Import Custom Reference to access the Import Custom References page.

Figure 150: Import Custom Reference Screen

2. Select the file to import, the type of information, and the type of import you want to perform from the drop-down lists.

3. Click Preview to open a pop-up listing the information to be imported. When finished, click Close in that pop-up to close the window.

4. Click Import to import the data.

About the Batch DRG Grouper The Batch DRG Grouper enables you to define search criteria for a group of records in order to regroup them. This feature uses the same setup information used by Clintegrity to group individual encounters. The Batch DRG Grouper handles up to 10,000 records at a time. The regrouped records may be saved to the database or sent to a file.

About the Batch Outpatient Grouper The Batch Outpatient Grouper enables you to define search criteria for a group of records in order to regroup them. This feature uses the same setup information used by Clintegrity to group individual encounters. The Batch Outpatient Grouper handles up to 10,000 records at a time. The regrouped records may be saved to the database or sent to a file. This feature enables you to regroup all the encounters for the same grouper types, such as APC, ASC, and EAPG.

NOTE: The EAPG grouper type will only display if you have the EAPG license.

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Batch Import Scheduler With the Batch Import Scheduler, you can set up a recurring batch file import. The import can be scheduled to run at a particular time and day, and occur once or at a regularly scheduled interval.

How to ...

Schedule Batch Import

1. Select Coding/Abstracting\Setup\Batch Import Scheduler to open the Import Scheduler page.

Figure 151: Batch Import Scheduler Screen

2. To search for an schedule, select search criterion from the Search drop-down list, enter a search item in the text field, and click Go.

3. To delete a schedule, click the checkbox at the end of its line and click Delete.

4. To add or edit an import schedule:

a. Click Add New to add a schedule or click the Name link of a schedule to edit it. The form view of the Setup Import Scheduler page appears.

Figure 152: Schedule Information Form View Screen

132 Chapter 4 Coding Setup b. Fill in the fields. Fields marked with an asterisk (*) require data.

Table 44: Schedule Information Fields and Descriptions

FIELD DESCRIPTION

*Facility Select the facility for which you are importing encounters. Only those facilities that you have permission to access are displayed in this list.

Multi-Facility Import Check this checkbox if the import file contains encounters for multiple facilities and you have permission for all facilities. NOTE: If this is a multiple facility import, the facility you select from the Facility drop-down list determines the validation rules to be used for all encounters in the import file regardless of associated facility for the encounter.

*File Layout Select the file format layout of the import file. To add file layouts, see Create File Layouts on page 126.

*Import File Enter the name of the file to import. The file must be in the location specified in the Admin\Preferences. You can click the lookup icon to select the file from a list of import files in the import directory.

*Patient Type Select the patient type for encounters being imported. Encounters in the import file that have no patient type listed are also imported. Encounters with a patient type different than the one you select are not imported. To import those encounters, run the import process again for that patient type.

*Start Date & Time Enter the time and day that the import should start to run. Time should be in the format HH:MM and date should be in the format MM/DD/YYYY.

Time Zone Select the time zone in which the import will run.

Cycle Select the frequency with which to run the import, for example, daily, weekly, or monthly. c. To save your changes, click Save, or to discard changes, click Cancel.

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Batch Export Scheduler With the Batch Export Scheduler, you can set up a recurring batch file export for encounters. The export can be scheduled to run at a particular time and day, and occur once or at a regularly scheduled interval.

OSHPD exports must be done manually. See Export Encounters on page 193 for more information.

How to ...

Schedule a Batch Export

1. Select Coding/Abstracting\Setup\Batch Export Scheduler to open the list of scheduled exports.

Figure 153: Batch Export Scheduler Screen

2. To search for an export schedule, select search criterion from the Search drop-down list, enter a search item in the text field, and click Go.

3. To delete an export schedule, click the checkbox for the schedule and click Delete.

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4. To add or update an export schedule:

a. Click Add New to add a new schedule, or click the schedule’s Export Filename link to edit it. The form view of the export scheduler appears.

Figure 154: Export Setting Form View Screen

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b. Fill in the fields. Fields marked with an asterisk (*) require data.

Table 45: Export Setting Fields and Descriptions

FIELD DESCRIPTION

*Facilities Select the facilities for which you want to export encounters.

*File Layout Select the export file layout. To add file layouts, see Create File Layouts on page 126.

*Export File Name Enter the name for the export file. If a file already exists with this name, it is overwritten.

*Patient Types Check the checkboxes for the patient types to export. More that one patient type can be exported at one time.

Admit Date Range Enter the admit date range. You can choose one of the two types of dates.

 To define a time period, click Specific Dates and fill in the dates for the beginning and end of the period, for example, 06/01/2007 to 06/30/2007, or click the Calendar icon to choose the dates from a calendar. (All dates must be entered in this format MM/DD/YYYY.) ( )

 To use a predefined time period, such as Today, Last Week, Last, or Month, click Relative Dates and select a time period from the Date Range drop-down list.

Discharge Date Enter the discharge date range. You can choose one of the two types of Range dates.

 To define a time period, click Specific Dates and fill in the dates for the beginning and end of the period, for example, 06/01/2007 to 06/30/2007, or click the Calendar icon to choose the dates from a calendar. (All dates must be entered in this format MM/DD/YYYY.) ( )

 To use a predefined time period, such as Today, Last Week, Last, or Month), click Relative Dates and select a time period from the Date Range drop-down list.

Last Modified Date Enter the last modified date range. You can choose one of the two types of Range dates.

 To define a time period, click Specific Dates and fill in the dates for the beginning and end of the period, for example, 06/01/2007 to 06/30/2007, or click the Calendar icon to choose the dates from a calendar. (All dates must be entered in this format MM/DD/YYYY.) ( )

 To use a predefined time period, such as Today, Last Week, Last, or Month), click Relative Dates and select a time period from the Date Range drop-down list.

*Coding Status Select the coding status you want to export from the drop-down list.

Compliance Status Select this option to export only those coding encounters which satisfy the Released applied filter conditions, and which also have an additional filter of a compliance release status. If this option is unchecked, all coding encounters satisfying the applied filter conditions are exported, irrespective of their compliance release status. NOTE: You can also check or uncheck this option by using the SPACEBAR.

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FIELD DESCRIPTION

*Abstracting Status Select the abstracting status you want to export from the drop-down list. NOTE: Only required if you are licensed for Abstracting.

*Start Date/Time Enter the time and day that the export should start to run. Time should be in the format HH:MM and date should be in the format MM/DD/YYYY.

Time Zone Select the time zone in which the export will run.

Cycle Select the frequency with which to run the export, for example, daily, weekly, or monthly.

To To send status reports via an e-mail message when the export is run, enter the e-mail addresses separated by a semicolon. The e-mail server is set up in Admin\Preferences. For information, see the System Administration Guide. c. To save your changes, click Save, or to discard changes, click Cancel.

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Chapter 5 Patients

Working with patients is, of course, fundamental to working in your Clintegrity application. The pages you access from the Patients tab and the tasks you can perform on them are discussed in this section.

 Overview of Patient Information (see page 139)

 View Patient Page (see page 141)

 Patient Info Banner (see page 143)

 Amendments and Restrictions (see page 158)

 Encounter List (see page 160)

Overview of Patient Information Before you begin working in Clintegrity, you should understand the hierarchy of patient information. Just as there is a hierarchy to locations in a hospital— hospital, unit, room, and bed — there is a hierarchy to the storage of information about a patient. The Clintegrity Patient hierarchy is organized this way.

 Enterprise Information – The enterprise information consists of the following:

 Social Security Number (SSN)

 Enterprise number

 Sex

 Date of Birth

 Address

 Confidentiality Level The Enterprise Number is optional and is generally used when Clintegrity is installed in a multi-facility organization.When a new patient is added, the system verifies that the combination of enterprise number, if used, and SSN do not already exist in the database. This number is not associated with a particular facility within an enterprise, but with the patient.

 Facility Information – Clintegrity, along with most hospital information systems, stores Medical Record Numbers (MRN) which uniquely identify each patient associated with a facility. This record consists of the MRN, MRN alias, name, and alias names (an example of an alias is a patient who has different names before and after marriage). Each MRN is attached to a single enterprise number, if used. When you add a new patient, the system verifies that the MRN does not exist in the facility for which you are attempting to add the patient.

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 Encounter Information – Each visit that a patient makes to a facility in the enterprise is called an encounter. For billing purposes, encounters are tracked by an account number. Each account number is unique for that patient’s visit. Some facilities use recurring or series account numbers to cover recurring outpatient treatments, such as a month’s worth of physical therapy at two times per week. The encounter record consists of admit and discharges dates, patient type, visit type, payor information and encounter based confidentiality level.

Imported Data If patient information is imported from another system, Clintegrity checks if the patient exists in the Clintegrity system before the information is imported. There are different kinds of matches that can occur. Each has a different result.

 If the patient is not identified in the Clintegrity database, then enterprise and facility information is added for the patient.

 If the patient is identified in the Clintegrity database by SSN and enterprise number, but that doesn’t match the patient information in the import file, then the record is not imported and is recorded as an exception.

 If the patient is identified in the Clintegrity database by SSN and enterprise number, but the MRN does not match, the enterprise and facility information is updated and the MRN information in the import file is added as an alias.

Data Collected On the patient information pages, two types of data are collected.

 Demographic data, meaning information about the patient, such as name, MRN, and address. You enter, and review, demographic data on the Patient Info page.

 Encounter date, meaning information about each specific encounter for a given patient, such as type of visit, details of the visit, and charges related to the visit. You enter, and review, encounter data on the Encounter List page. The encounter date defaults to the admit date.

You can retrieve these records in a variety of ways, searching on patient name, medical record number (MRN), date of birth (DOB), social security number (SSN), enterprise number, facility and confidentiality level. This data can also be archived and restored. See the System Administration Guide.

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View Patient Page There are several locations within Clintegrity where you can look up patients.

 On the View Patients page, you can search for one or several patients.

 On some pages there are patient-identifying fields—such as Last Name or MRN—which have a lookup button next to the field. Click the lookup button to open the Select a Patient page.

How to ...

Look Up a Patient

1. Select the Patients tab to access View Patients page.

Figure 87: View Patients Page

2. Search for a specific patient or for patients that have a common element.

a. Choose a search option from the first drop-down list.

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Table 46: View Patient Search Options and Descriptions

SEARCH OPTION DESCRIPTION

Patient Name Select the Patient Name option from the drop-down list, and type the patient’s name in the text field.

MRN Select the medical record number used by the patient in the facility for which the patient is being created. Different facilities can use different MRNs for the same patient.

Account # Select the Account # option from the first drop-down list to search for a specific patient or patients. NOTE: When you search by this option, a separate column for Account # is displayed.

Admit Date Select the Admit Date from the first drop-down list and type the admit date in mm/dd/yyyy format in the text field.

Discharge Date Select the Discharge Date from the first drop-down list and type the admit date in mm/dd/yyyy format in the text field.

DOS Select the DOS option from the drop-down list and type in the date of service in mm/dd/yyyy format in the text field.

Provider Select the Provider option in the drop-down list and type the provider’s name in the text field.

Facility Select the Facility option from the drop-down list to search for a patient or patients.

Parent/Child Select the Parent/Child Acct# option from the drop-down list and type the Acct # account number in the text field.

b. Enter the search specifics in the text field and click Go. For example, choose Patient Name and then enter Jones, or choose MRN and then enter 786. c. Review the search results displayed in the list view of the Patients page. Only patients for facilities and confidentiality levels that you have access to are shown in this list.

3. From the list of search results, you can:

Figure 88: View Patients Screen - List View

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 Review patient information. Select the patient from the list and follow the instructions in Add or Change Patient Information. (To review patients, you must have the confidentiality access to Patient Information and Facility.)

 Deactivate a patient account by unchecking the Active checkbox at the end of its line and clicking the Update button.

 Add a completely new patient information. Click the Add New button, then fill in the fields as described in Add or Change Patient Information.

Patient Info Banner When you select an encounter, you are taken to the Coding screen that displays the Patient Information Banner.

To add or make any changes, such as, viewing, adding, editing, changing status or merging patients you must.

 Belong to a group with specific permission to perform those tasks.

 Have an appropriate access level.

The access level correlates to a patient’s confidentiality level. For example, if your access level is 3, you cannot view, add, or change patients or patient encounters with a confidentiality level of 4 or 5.

How to ...

Add or Change Patient Information You can collect and change all patient information on the Coding screen.

Show Patient Details button Edit Patient Details button

Figure 89: Coding Screen

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1. In the Patient Information banner, click the Edit Patient Details button to enter or update patient information. ( )

Table 47: Patient Information Banner Fields and Descriptions

FIELD DESCRIPTION

Patient Name Enter the patient’s name.

MRN Enter the medical record number used by the patient in the facility for which the patient is being created. Different facilities can use different MRNs for the same patient. The information in this field cannot be edited.

Account # Enter the account number. The information in this field cannot be edited.

Sex Select the patient’s sex from the drop-down list.

Age The value is auto-populated in this field.

*Patient Type Select the patient type from the drop-down list.

Visit Type Select the visit type from the drop-down list.

*Coder Select the coder from the drop-down list.

*AD Enter the admit date or click the Admit Date Calendar Lookup icon to choose a date from a calendar. ( )

DD Enter the discharge date or click the Discharge Date Calendar Lookup icon to choose a date from a calendar. ( )

Discharge Status Enter the discharge status or click the Discharge Status Lookup icon to choose a discharge status from a pop-up window. ( )

Payor Select payor information from the drop-down list.

DRG The DRG value is auto-populated in this field.

Version Select version from the drop-down list.

DOB Enter the patient’s birth date or click the Date Of Birth Calendar icon to choose a date from a calendar. ( )

Birth Wt Enter the birth weight.

Attending Enter the attending provider information or click the Provider Lookup icon to choose a provider from a pop-up window. ( )

Facility The facility field is auto-populated.

Admit Time Enter the admit time.

Discharge Time Enter the discharge time.

LOS The length of stay value is auto-populated (Admit Date - Discharge Date).

AMLOS Arithmetic Mean Length of Stay. A LOS that is calculated taking into account all LOSs. Used to compare to other hospitals. NOTE: The value is auto-populated.

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FIELD DESCRIPTION

GMLOS Geometric Mean Length of Stay. A LOS that is calculated taking into account geographic factors, cost outliers and transfers. NOTE: The value is auto-populated.

Weight The relative value established by CMS and NY State for DRG NOTE: The value is auto-populated.

Secondary Payor Select secondary payor information from the drop-down list.

Total Charges Enter total charges.

Secondary DRG The secondary DRG value is auto-populated only when you enter the secondary payor information.

Reimb The reimbursement amount is auto-populated.

Bill Type Enter the bill type information or click the Bill Type Lookup icon to choose a bill type from a pop-up window. ( )

Coding Status Select the Coding Status of the encounter.

Abstracting Status Select the Abstracting Status of the encounter.

2. To save your changes, click the Done Edit button. ( )

About Merging Patient Records You can merge patients when a person’s information has been entered under two different names and thus assigned two Medical Record Numbers (MRN). The Merge function merges the encounters to the correct MRN. There are two decisions you must make before merging patient records.

 Determine which MRN is to be retained as primary, the Original MRN or the Active MRN.

 Determine which patient demographic information is to be retained as primary, the original demographic information or the active demographic information.

The following table can help you determine the sequence in which the MRNs should be merged. Using the first two columns of the table, find the row that shows both of your decisions (the MRN should be primary and the patient demographic information that should be primary). By identifying these two elements, the sequence of record selection for the merge and the merge action to be used is identified (see the information in the First Record to Select for Merge and Merge Action columns in the row that shows your decisions).

Table 48: Merge Action Columns

PATIENT DEMOGRAPHICS VOLUME MRN RETAINED FIRST RECORD TO MERGE ACTION RETAINED AS INFORMATION AS PRIMARY SELECT FOR MERGE PRIMARY RETAINED

Original MRN Merge From Patient Original MRN Original Demographics Original Volume

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PATIENT DEMOGRAPHICS VOLUME MRN RETAINED FIRST RECORD TO MERGE ACTION RETAINED AS INFORMATION AS PRIMARY SELECT FOR MERGE PRIMARY RETAINED

Original MRN Merge into Patient Active MRN Active Demographics Active Volume

Active MRN Merge From Patient Active MRN Active Demographics Active Volume

Active MRN Merge into Patient Original MRN Original Demographics Original Volume

Example – You need to retain the original MRN as the primary MRN and the original patient demographics as the primary demographics (first row in the table above). In this scenario, you first search for and select the original MRN, and during the merge process, you select the merge action Merge From Patient. It retains the original MRN and the original demographic information.

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How to ...

Merge Patient Records You can merge a patient’s encounters, documents, volumes, and deficiencies from one facility to another, within the enterprise. This removes the patient from the first facility.

1. Use the table on page 145 to determine if you should select the original MRN.

Figure 90: View Patients Page

2. In the Patients tab, select a Patient Name to display the Patient Info screen; and the Patient Info window appears, displaying the demographic information.

3. In the Facility Information section of the window, click the Merge link. The Merge Patient window appears.

Figure 91: Patient Information Screen

4. Click Cancel to discard your changes.

5. On the Merge Patient pop-up window, enter the patient’s name to which you want to merge this MRN and click the Go button to begin the search. A list of patients matching your search appear. You may also search by SSN, DOB, or Enterprise number.

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6. Select the Patient Name.

Figure 92: Merge Patient Page with Search Drop-down List

7. The Merge Patient window appears with the following notification. A Patient already exists at this facility, and the patients need to be merged.

Figure 93: Merge Patient Window with Notification

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From the Primary Patient MRN list, select the Merge From Patient option. You may click the Cancel button to discontinue this action if performed in error.

8. Click OK to save the changes.

Figure 94: Merge Patient pop-up Also, if there is incorrect information in the Primary MRN patient information, (that is, telephone number, next of kin, etc.) after the merge is completed, the user can manually update this information through the Patients tab.

9. Click the Merge button. If a Patient A is merged with a Patient B, then the active Patient B Encounter List automatically displays a list of all encounters for inactive Patient A and active Patient B merged together. Documents and Volumes also contain the merged list. The application displays the main Patients tab and a listing of patients in the database automatically appears.

NOTE: Also, the patient_facility.merged_date field in the database help to collect the date and time, the merge occurs.

Figure 95: View Patients Screen - List View

Merging Encounters using HL7 Messages Once Clintegrity receives HL7 merge message, it will automatically merge the MRG segment MRN with the PID segment MRN.

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The following are possible HL7 events for merging:

 A18 – Merge patient information

 A34 – Merge patient information (Patient ID only)

 A40 – Merge patient (Patient Identifier List)

 A43 – Move patient information (Patient Identifier List, Unmerge event)

 A44 – Move account information (Patient Account Number)

 A47 – Change patient identifier list

Expected Results by Module

 Chart Completion – Encounters are merged under the primary MRN, and the patient information is updated as appropriate with deficiencies intact per encounter and displaying correct volume information.

 Correspondence Management:

 Requests - Requests are linked to the primary MRN and the patient information is updated. Items and billing information is intact. Requests from the alias MRN are linked to the primary MRN appropriately.

 Orders - Orders from the alias MRN are linked to the primary MRN and the patient information is updated.

 Chart Locator – The alias as well as the primary MRN are listed. Patient information is updated and volumes are linked. First and last contact (indicated by the admit date for the first encounter and the discharge date of the last encounter within that volume) are updated to reflect all encounters within that volume. Manual entry is required for volume detail as described in Link Volumes (see page 156). Any reservations, volume history and detailed volume information for volumes associated with the unretained MRN is deleted. Two different reorganizations are possible.

 The volumes are combined into one folder. Relink the volumes, and inspect and update the volume information. See the Clintegrity Chart Locator User Guide for more information on working with volumes

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 The volumes are reorganized into several folders, and the volumes need to be renumbered, added, or deleted to support the reorganization. See the Clintegrity Chart Locator User Guide for more information on working with volumes.

Figure 96: Chart Locator - Working with Volume Screen

 Coding – The patient name is not updated, but the MRN is. Whether you search by name or MRN, all linked encounters are found.

Figure 97: View Encounters Screen by MRN Search

Figure 98: View Encounter Screen by Patient Name Search

 Compliance – The patient name is not updated, but the MRN is. Whether you search by name or MRN, all linked encounters are found.

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 EDM – Encounters are linked to the primary MRN and the documents are intact.

 e-Signature – The patient information is updated to the primary MRN and deficiencies are intact.

NOTE: This section displays the merge functionality with the renamed VOLUME_ID(volume name) of the source patient. For example, if the Source Volume_Id = VolumeA and SID= 123, then the renamed volume_Id = volumeA_123. The previous volume Id can be used while unmerging the patients to restore the original volume Id.

Multiple Merges There are two general scenarios when more than one MRN has been merged into the active patient:

 If more than one MRN has been merged into the active patient, Unmerge hyperlink is displayed for all the patients merged into the active patient in Merged MRNs section.

 An MRN (Patient C) has been merged into active Patient B. Active Patient B is then merged into active Patient A. The Patient B appears in the Merged MRNs section with Patient C indented under it. Here Unmerge hyperlink displays only for Patient B. After unmerging Patient B from Patient A, the Unmerge hyperlink displays for Patient C. The screen is an example of multiple merges.

Multiple merge

Figure 99: Multiple Merges Screen - Example

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Unmerge MRNs The Merged MRNs section in the Patient Info screen displays the MRNs that were merged into the current patient and are no longer active. For previously merged MRNs, the Unmerge hyperlink displays.

Click Remove hyperlink to remove MRN alias Merged MRNs section Click Unmerge hyperlink to unmerge MRNs

Figure 100: Patient Info Screen - Unmerge MRNs

You can unmerge the merged MRN’s Encounters, Documents, Volumes, or Deficiencies automatically. Follow the steps outlined below to perform unmerging:

1. Click Unmerge link for the merged patient under the Facility Information section. A screen is displayed. This screen includes Original MRN and Active MRN labels with all items to be separated mentioned as shown below:

Figure 101: Unmerge - Original and Active MRN Labels

2. Select the Encounters, Documents, Volumes, and Deficiencies to be unmerged. These Encounters, Documents, Volumes, and Deficiencies will move back to the original MRN.

3. Click Save. A confirmation message is displayed.

4. Click OK to continue with the unmerge.

NOTE: Merge or unmerge can happen between different facilities or within the same facility. However, if the merge is done for patients in different facilities, neither the MRN alias nor the Patient Name alias is created and the patient remains active.

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If the unmerge is initiated (currently an inactive MRN) and the system finds an active MRN with the same value, the Unmerge hyperlink and the Merge MRNs section are disabled and the following error message displays:

Unmerge cannot be performed. Active duplicate MRN already exists.

NOTE: If the same user closes and reopens the same encounter or a different user opens the encounter, the Unmerge hyperlink is enabled.

Unmerge error message

Figure 102: Unmerge Error Message

Unmerging Encounters using HL7 Messages Clintegrity accepts HL7 unmerge messages. This allows an automated unmerge of a patient’s data along with their encounters, documents, volumes, and deficiencies. Edited or deleted encounters, documents, volumes, and deficiencies are tracked and moved back to the original MRN (where needed) when unmerged. Newly added encounters, documents, volumes, and deficiencies remain with the merged-to MRN or the Active MRN.

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Patient Encounter Volumes

How to ...

 Add a New Volume (see page 155)

 Delete a Volume (see page 155)

 Link Volumes (see page 156)

Add a New Volume

NOTE: You can only add a new volume if the Create a Volume checkbox is checked under Admin\Users/Outpatients and Encounter Data.

1. Select Record Management\Patient.

2. Click the Encounters List tab.

3. Click one account number contained in the new volume.

4. Click the Add New button in the Volume section of the window.

5. Enter Volume information and click Save.

6. Click the checkbox in the Volume section to new volume with the encounter.

7. Click OK to save the changes.

8. If necessary, you can repeat steps 4 and 7 to link additional encounters to the new volume.

9. When you are finished, click the Save button to save your changes (to discard changes, click Cancel).

Delete a Volume

1. Select Record Management\Patient.

2. Click the Encounters List tab.

3. Click any account number.

4. Click the Remove link associated with the volume number to be deleted.

5. Click OK to save the changes.

6. When you are finished, click the Save button to save your changes (to discard changes, click Cancel).

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Link Volumes To link the volumes to the appropriate encounter, follow the steps given below.

NOTE:

 Reservations for one or more Original MRN volume are discarded and have to be manually entered as appropriate once the volumes have been linked to the primary MRN.

 Volume detail is lost for one or more Original MRN volume and have to be manually entered once the volumes have been linked to the primary MRN.

 Relinking must be performed to continue working with any incomplete encounters and deficiencies when the encounters were previously linked to a volume under the incorrect MRN.

1. From the Patients tab, search for the correct patient MRN.

Figure 103: View Patients Page - MRN Search

2. Select the primary MRN by clicking on the patient’s name link.

3. Click the Encounter List link.

Figure 104: Encounter List Page

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4. Select an account number. The encounter and volume information is shown.

Figure 105: Encounters Update Screen

5. In the Volumes area of the window, if the checkbox next to the volume number is not checked, check it. This links the volume to the primary MRN.

Figure 106: Volumes Area Window

6. Click OK to save the changes.

7. Repeat step 104 through step 106 for each account number listed to ensure the volumes are linked to the primary MRN.

8. Upon completing the linking of volumes for all encounters listed on the Encounter List page, click Save.

NOTE:

 Any reservations for the unretained MRN’s volumes are discarded and have to be manually entered as appropriate. See the Chart Locator User Guide for more information on working with volumes.

 Volume detail is lost for the unretained MRN’s volumes and has to be manually entered. See the Chart Locator User Guide for more information on working with volumes.

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Amendments and Restrictions The second divider link under the Patients tab opens the Amendments/Restrictions page.

How to ...

 Add, Change, or Remove Amendments (see page 158)

 Add, Change, or Remove Restrictions (see page 159)

Add, Change, or Remove Amendments Patients or their representatives can amend the patient’s protected health information (PHI) by submitting a written request to the provider. The hospital must accept the amendment unless:

 The hospital does not possess the information that is the subject of the amendment.

 The patient doesn’t have the right to inspect the PHI that is the subject of the amendment.

 In either case, the hospital should not allow the existing PHI to be deleted, overwritten, or altered.

1. From a patient record, click the Amendments/Restrictions divider tab to access the Amendment/Restrictions page.

Figure 107: Amendment/Restrictions Screen

2. Decide what you want to do from this page. You can

 Add an amendment by filling in the fields in the Amendment Requests section.

 Click the Add link at the end of the amendment’s line to add another amendment.

 Click the Remove link at the end of the amendment’s line to remove the amendment.

 Add a restriction.

3. To save any changes, click the Save button. To discard changes, click Cancel.

4. Fields on this page include:

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Table 49: Amendment Fields and Descriptions

FIELD DESCRIPTION

Status Select a status from the drop-down list.

 Received – This is the initial status for any new amendment.

 Approved – If the amendment is approved, an icon appears next to the patient’s name in the list view of the View Patient’s page and a warning appears if an attempt is made to create a request or order for the patient’s information. If patients are merged, any amendments are moved to the primary patient. No amendment flag appears next to the patient’s name on reports.

 Cancelled – Indicates that the amendment is cancelled.

 Denied – If the amendment is denied, the patient must be notified in writing that their request for amendment was denied. They must be provided with the basis for denial, given an explanation of how they might file a statement of disagreement and be notified of their right to submit a written statement of disagreement.

Comment Enter any comments about the amendment.

Add, Change, or Remove Restrictions A patient can request restriction of the use or disclosure of protected health information. Reasons might be to carry out options for treatment, payment, or healthcare, or to provide disclosures of limited information for specific purposes. The provider is not required to agree to any restrictions, but in the Clintegrity system you can document the restrictions, whether they are agreed to or not.

When, during creation of a request in Correspondence Management, you select a patient with a restriction, the system warns you that there is an approved restriction on file for the patient.

1. From a patient record, click the Amendments/Restrictions divider tab to access the Patient: Amendment/Restrictions page.

2. Decide what you want to do from this page. You can:

 Add an amendment.

 Fill in the fields in the Restrictions section to add or change a restriction.

 Click the Add link at the end of the restriction’s line to add additional lines.

 Click the Remove link at the end of the restriction’s line to remove it.

3. To save your changes, click the Save button. To discard changes, click Cancel.

Fields on this page include:

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Table 50: Restrictions Fields and Descriptions

FIELD DESCRIPTION

Status Select a status from the drop-down list.

 Received – This is the default status for any new restriction.

 Approved – If approved, an icon appears next to the patient’s name in the list view of the View Patient’s page indicating a restriction is present. A warning appears if an attempt is made to create a request or order for the patient’s information. If patients are merged, any restrictions move to the primary patient. No restriction flag appears next to the patient’s name on reports.

 Cancelled – Indicates that the restriction is cancelled.

 Alternative Suggested – If the restriction is denied, this status indicates that the patient was notified of an alternative to the restriction.

 Denied – If the restriction is denied, you must adhere to HIPAA standards governing disclosures to family members, relatives, close personal friends, and other persons identified by the patient.

Comment Enter any comments about the restriction.

Encounter List The third divider link under the Patients tab opens the Encounter List page.

Figure 108: Encounter List - Divider Link

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How to ...

 View Encounter List (see page 161)

 Add New Encounter (see page 162)

 Reassign an Encounter (see page 163)

 View History (see page 164)

 Delete an Encounter (see page 165)

View Encounter List

1. On the Encounter List page, click the + icon next to the facility to expand the list of encounters.

Figure 109: Encounter List Page

2. Review the information about the patient and about the origin of the patient’s record displayed on this page. (This information is not editable.)

Table 51: Encounter List Fields and Descriptions

FIELD DESCRIPTION

MRN Patient’s medical record number. NOTE: The MRN in this field might appear without any hyphens, if you specified any in its format (in Admin\System Configuration\Facility). However, the hyphens appear correctly on page headers and in any reports you print.

Origin System The Clintegrity product in which the patient was originally created.

Origin Mode The creation mode, for example, Imported or Entered or Data Migration.

Origin User The user ID of the user that created the patient.

Create Date The patient’s creation date.

Last Modified The last date the patient was modified. Date

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3. Decide what you want to do from this page:

 Add New Encounter (see page 162)

 Reassign an Encounter (see page 163)

 View History (see page 164)

 Delete an Encounter (see page 165)

Add New Encounter

1. From the Encounter List page, click Add New to open the Add New Encounters pop-up window.

Figure 110: Add New Encounters Pop-up Window

2. Enter or select from the drop-down lists, the specifics of the new encounter, including:

Table 52: Add New Encounters Fields and Descriptions

FIELD DESCRIPTION

Admit Date/Time Patient’s admission date and the time of the admission.

Discharge Patient’s discharge date. Date/Time

Discharge Status Status for patient’s discharge.

Account # Patient’s account number.

Patient Type Type of encounter, inpatient, outpatient, etc.

Parent Account # If account number is a child account, the parent account number.

Visit Type Type of visit.

Payor Payor for encounter.

Charges Charges for encounter.

Attending Provider Admitting physician.

Bill Type Bill type for the encounter.

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FIELD DESCRIPTION

Confidentiality This is the confidentiality level for the encounter. The confidentiality level limits Level permission to view the encounter. Users must have an access level as high or higher than the confidentiality level to view or edit the encounter. Five is the highest level. The confidentiality level can be set to a different level than the patient’s confidentiality level. For example, you may want to set the encounter level confidentiality level higher than the patient confidentiality level if the patient was admitted for psychiatric or chemical rehab type care. So that the patient is an ordinary patient for other visits but the psych or chem rehab visit is medical information that is more protected.

3. To specify the volume in which this encounter should reside:

a. Click Add New.

b. Enter the volume information and click Save.

c. Check in the checkbox to associate the volume with the encounter.

4. When you are finished click OK to save your changes, or click Cancel to discard them.

Reassign an Encounter You can reassign an encounter from one patient to another. This removes the encounter from the first patient, and makes the encounter part of the second patient’s records.

1. Select the Reassign link at the right of the encounter you want to reassign.

Figure 111: Encounter List Page with Reassign Link

2. On the Search window that pops up, enter the search parameters needed to find the patient to whom you are reassigning this encounter. See Look Up a Patient for help with searching.

3. When you find the patient, open their Patient Info page.

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4. Enter the relevant information into the fields.

Table 53: Reassign Lookup Fields and Descriptions

FIELD DESCRIPTION

Enterprise Enter the patient’s enterprise number.

Confidentiality The patient’s confidentiality level limits permission to view the patient. Users Level must have an Access Level as high or higher than the patient to view or edit that patient’s information: 5 is the highest level. NOTE: You can also set a separate confidentiality level for encounters. See View Encounter List for more information.

Volume From the drop-down list, select a volume, choose None for no volume, or choose Add New to add a volume. When you select Add New, a pop-up window appears. Fill in the fields for the new volume and click Save.

5. Click Save to complete the reassignment of the encounter.

View History

1. Click the History link on an encounter to see its historical information. This information is not editable.

Figure 112: History Lookup Window

Table 54: History Lookup Fields and Descriptions

FIELD DESCRIPTION

User ID The person who entered the data. Click header to sort the list by users.

Activity Whether an encounter was viewed or changed.

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FIELD DESCRIPTION

Product Clintegrity product for which the entry was made. Click header to sort the list by products.

Date and Time The date and time that the entry was made. Click header to sort the list chronologically.

2. Click the print icon to print a copy of the history information or click the Close button to return to the View Encounters page.

Delete an Encounter If you have permission to delete encounters and the encounter does not contain critical encounter data, a Delete link for the encounter appears on the Encounter List page. If an encounter does include critical data, but should be deleted, do the following.

 For Coding/Abstracting or Compliance, first delete the encounter in Coding or Compliance (this deletes the critical encounter data at the coding/compliance level). You can then delete the encounter at the patient level.

 For all other Clintegrity products, first delete the critical encounter elements from the encounter and then delete the encounter at the patient level.

The following is a list of the critical data elements for each product:

 Electronic Document Management – Documents for the encounter

 Correspondence Management – Request data

 Chart Completion – Any of the following data:

 Deficiencies

 Deficiency history

 Encounter is marked Complete at Discharge

 Chart Locator – Any of the following data:

 Volume with a volume type other than Date is linked to the encounter

 Encounter linked to volume with a volume type of Date and the volume has a checkout history and reservations

1. To delete an encounter, from the Encounter List page for a patient, click the Delete link for the encounter to be deleted.

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Click here

Figure 113: Encounter List Page with Delete Link

2. In the comments window, you may enter the reason you are deleting the encounter and then click OK. In the confirmation window, click Yes to delete the encounter.

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Chapter 6  Working With Encounters

Think of a patient encounter as the file that you work with in a Coding or  Abstracting work session. To add codes to a patient’s record, you open or create an encounter for that patient. Once an encounter is open, you can add codes to the patient’s codelist. When you are finished, you save or close the encounter, or if you have an interface to a host system, you send the completed encounter to the host system.

There are several different courses of action you can take in Coding to create, work on, and complete encounters. Here is an overview of the tasks you can perform in the Coding/Abstracting process:

 Finding Existing Encounters (see page 167)

 Work on Encounters (see page 174)

 Managing Electronic Documents (see page 190)

 Completing the Coding Process on Encounters (see page 192)

Finding Existing Encounters To work with Coding, you can import encounters into the Clintegrity system using a batch interface. The batch interface imports a file that is made up of a group of encounters using the Import function which is described in this section. Importing encounters updates the master patient record in Clintegrity, which can be viewed on the Patients tab, as well as the coding encounter record, which can be viewed on the Coding/Abstracting\View Encounters page.

NOTE: To import encounters you must belong to a group that has permission to import encounters. See your system administrator to get this permission if you do not have it and need it.

 Import Encounters (see page 168)

 Regroup Inpatient Records (see page 170)

 Regroup Outpatient Records (see page 170)

 Advanced Search for Encounter (see page 173)

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Import Encounters

1. Select Coding/Abstracting\Setup\Import to access the Import screen.

Figure 114: Import File Window

2. Select the facility for which you want to import encounters from the Facility drop-down list,. Only the facilities that you have permission to access are displayed in this list.

3. Enter the name of the file to import in the Import File field. The file must be in the location specified in Admin\Preferences. If you do not know the name of the file, click the Lookup icon to see a list of import files in the import directory.

4. Select the file format of the import file from the File Layout drop-down list.

5. Select a Patient Type by clicking the radio button for the appropriate type. If there are encounters in the import file with no patient type listed, those encounters are also imported. If there are encounters with a patient type different than the one you choose here, those encounters are not imported. To import those encounters, you need to run the import process again for that patient type.

6. Click Preview to preview the import file. The preview window can contain up to 30 encounters.

Figure 115: Import Preview Window

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7. If you want to preview more information about the encounters you are importing, click one of the encounter’s links on the preview screen. The Import Preview Details window appears (a portion of the screen is shown here).

Figure 116: Encounter Details Window Click Back to List to return to the preview, or click Close to return to the Import page.

8. Click Import to import the file.

9. The progress of the import is shown on a status bar. When the import process is complete, results are displayed.

NOTE: You can click Cancel to stop the import process.

10. If you are not satisfied with the results of the import, click Cancel to reverse the import process. If you are satisfied with the results of the import, click Continue to complete the process.

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Regroup Inpatient Records When it is necessary to correct patient records, you can define up to 10,000 records to be corrected in a batch. You can limit the number of records processed by refining your search criteria. The preview feature enables you to verify that your search is under the record limit. The corrected records are saved to a file or updated in the database.

NOTE: When you click the Batch DRG Regroup link under Coding/Abstracting\Setup, you are redirected to Batch DRG Regroup page under Admin setup. For more details, refer System Admin Guide.

Regroup Outpatient Records When it is necessary to correct patient records, you can define up to 10,000 records to be corrected in a batch. You can limit the number of records processed by refining your search criteria. The preview feature enables you to verify that your search is under the record limit. The corrected records are saved to a file or updated in the database. This feature enables you to regroup all the encounters for the same grouper types, such as APC, ASC, and EAPG.

NOTE: When you click the Batch Outpatient Regroup link under Coding/Abstracting\Setup, you are redirected to Batch Outpatient Regroup page under Admin setup. For more details, refer System Admin Guide.

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Using the Real-Time Interface The Real-Time interface enables you to perform real-time encounter creation and compliance checking. The ability to perform real-time compliance checking depends upon the integration of Compliance and Coding/Abstracting or the integration of Compliance or Coding/Abstracting and another HIS system through the HL7 or Interlink interfaces.

An encounter can be created in another system and then opened in Coding/Abstracting for additional coding. When you finish coding an encounter in Coding/Abstracting, the encounter can be saved in an Incomplete status, which holds the encounter in the Coding/Abstracting system, or can be saved in a Complete status, which exports the encounter to the original system, if all errors were corrected. If the Facility Preferences are set to Self-Review, the encounter is submitted to Compliance for compliance checking. Compliance runs selection rules against the encounter and if the encounter is selected, the encounter can be corrected in Compliance. Encounters that are held in the Coding/Abstracting system can be accessed by searching for encounters by coding status on the View Encounters page.

This means you can create an encounter and submit it for compliance checking, and the Compliance system runs the validation and selection rules against the encounter. If the encounter is selected, it is treated no differently than any other selected encounter in Compliance.

When the user finishes reviewing the encounter in Compliance, the encounter can be saved in a Pending status, which holds the encounter in the Compliance system, or can be saved in a Reviewed status, which exports the encounter to the original system.

Encounters that are held in the Compliance system can be accessed from the View Encounters page by loading the encounter set with the process designate RT in the name. This encounter set is a list of all the encounters submitted to Compliance on a particular day using the Real-Time interface. There is no time listed for the encounter set, because real-time submissions are only tracked on a daily basis. Encounter sets created using the Real-Time interface can be reported on by selecting the Real-Time encounter sets.

There are some variations to how Compliance and Coding/Abstracting behave if they are interfaced using HL7 or Interlink.

To enable the Real-Time interface between Compliance and Coding/Abstracting, do the following:

 Configure IP/OP Selection rules in Coding/Abstracting.

See Configure Compliance OP Selection Rules ICD-10 on page 99.

 If you want to use custom rules, you must configure the custom rules in Compliance Selection Rules in Compliance. See the Clintegrity Compliance User Guide for more information.

 Configure the interface settings in Coding/Abstracting.

See Set Up Facility Preferences on page 53.

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Receiving Encounters Through the Real-Time Interface for Regrouping Single records can be passed from another system via HTTP. You must keep the databases in sync when the Update Database parameter is selected for the purpose of regrouping. For example, if a discharge disposition in Clintegrity is set to 01, the other system needs to pass 01 instead of another term, such as HOME.

When a different system passes Clintegrity data, Clintegrity regroups the data it is sent and sends back the result. It can only do this one record at a time. It is not possible to process batches of records at this time.

To process a batch of records, when the data is already in the Clintegrity database, see About the Batch DRG Grouper on page 131.

The data can be handled in one of the following ways:

 Data is passed to Clintegrity and passed back.

 Data is passed to Clintegrity, passed back, and stored in the Clintegrity database.

NOTE:

 The ICD-10 Code Set feature is available for HTTP Regroup for both Inpatient and Outpatient encounters.

 This ICD-10 Code Set feature is available only if you have the ICD-10 Coding license.

 Only the CMS OPPS and ASC Grouper are ICD-10 ready.

The type of action you want to take is indicated in the message by sending a value in the saveToDb field. The Update Database parameter is sent as:

 0 – Do not update database

 1 – Update database

Passing data to Clintegrity that is missing elements results in the assignment of an ungroupable DRG.

NOTE:

 The HTTP message inbound to Clintegrity requires sufficient information to create an encounter but if the Update Database parameter is sent without sufficient information, then you receive a failure message.

 If the encounter already exists and the Update Database parameter is sent, then: A duplicate encounter will not be created. The database data will be overridden by the HTTP data.

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Advanced Search for Encounter When reviewing encounters, you can perform an advanced search to find a specific encounter or group of encounters with a common element.

NOTE: You can also perform a basic search; see Open an Encounter for a Patient Already in the Database on page 180.

1. Click the Advanced Search link to open the Advanced Search page.

Advanced Search link on the View Encounters screen

Figure 117: View Encounters Screen - Advanced Search

2. Select an item in the field (categories or individuals, such as Diagnosis Code or Provider), select an operator, and enter a value [criteria you are setting for that field, such as a specific code (with or without decimal) or a name]. If a field that has a lookup table associated with it, the Value field changes to show a lookup icon associated with the field.

For more information on using these fields, see Setting Rule Condition Criteria on page 474.

Value entered can be Lookup icon appears along with or without with those fields that have decimal. lookup tables.

Figure 118: View Encounters Advanced Search Window

3. Click the Lookup icon. The lookup table opens up. The individual tables (Discharge Status, Provider, Diagnosis, Procedure, HCPCS, DRG and APC) continues to have their current functionality of ID or Description lookup. Only the ID posts into the Value field for the advanced lookup.

Figure 119: Code Lookup Window

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4. Click Go to apply these additional filters.

5. The list view of the View Encounters page appears again, populated with the results of your search.

 The page shows information about the patient including Account and MRN numbers, payor, charges, and dates of admission and discharge.

 Only encounters for facilities to which you have access appear on this list.

6. To review an encounter, select it from the list and follow the instructions to Entering Patient Encounter Information (see page 181). You can only review encounters for facilities to which you have access.

Work on Encounters This section explains how to do essential tasks while working with encounters.

 About the View Encounters Screen (see page 175)

 Creating a New Patient Encounter (see page 179)

 Opening an Existing Patient Encounter (see page 180)

 Entering Patient Encounter Information (see page 181)

 Icons from the Coding Screen (see page 184)

 Copy Codes (see page 188)

 View Encounter History (see page 187)

 Enter Encounter Notes (see page 185)

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About the View Encounters Screen Before you begin coding, you choose an encounter from the View Encounters page. When you click the Coding/Abstracting tab, this is the first page that appears.

Figure 120: View Encounters Screen

NOTE: If you set a specific search term as your default value in Set Up User Preferences (see page 47), it is shown.

Search Area At the top of the page, there is a search field and a link to perform a more detailed search. To perform a basic search, select a search option from the Search drop-down list, enter an item on which to search in the search field and click Go. For instruction on Advanced Search, see Advanced Search for Encounter.

Your search criteria are saved on this page either until you log out of the session or reset the criteria.

Click to select a search option Enter search item here. When ready to from the drop-down list. search, click here.

Figure 121: View Encounters Search Criteria Window

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Clintegrity Links and Add New Buttons In the upper right-hand corner of the page, there are Clintegrity links and the Add New Facility Encounter and Add New Physician button. To add a new encounter, you click Add New Facility Encounter or Add New Physician. For information on entering new encounter information, see Creating a New Patient Encounter.

Clintegrity links

Click to add a new encounter

Figure 122: Links and Add New Buttons

Code Books Button

In the upper right-hand corner of the page, next to the Add New Facility Encounter button, you can see the Code Books button. It allows you to perform a standalone code book search without creating a dummy encounter. The Code Books button functions the same as Add New Facility Encounter button. This button is available to users with add / edit or view coding permissions. On clicking the button, the patient banner collapses regardless of having the add / view coding permissions, thus not requiring to enter dummy encounter details. You can expand the patient banner and update / save the information contained in it, with add or edit permissions.

Figure 123: Code Book button

Figure 124: Collapsed Patient Banner

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Encounter List The lower half of the page displays the list of encounter available to you to review or code. If there are more encounters than fit on one page, that is indicated just below the list, on the left-hand side, by a notation that you are viewing a certain number page of a total number of pages. There are links to the next page of the list.

Click to see additional pages.

Figure 125: Encounter List Screen

The encounter list shows the following information. If a column head is underlined, that means that you can click the column head to sort the list by that kind of data.

Table 55: Encounter List Columns and Descriptions

COLUMN DESCRIPTION

A If the A-on-green icon is present, there are amendments to the patient’s record.

C If the C-on-red icon is present, the patient has a confidentiality level higher than 1.

R If the R-on-gold icon is present, there are restrictions on the patient’s record.

Alerts Status of the encounter in regards to changes in the documents or a critical field change after you have saved the encounter previously.

CLU Number of documents processed by CLU

Account # Account number for the encounter.

MRN Medical Record Number (MRN) for the encounter.

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COLUMN DESCRIPTION

Facility Facility with which the encounter is associated.

Patient Name Patient’s name.

Payor Party responsible for the encounter’s charges.

PT Encounter’s patient type (PT).

Charges Charges for the goods and service on the encounter.

Admit Date the patient was admitted for services.

Discharge Date the patient was discharged after receiving services.

Status Encounter’s Abstracting, Coding, and Compliance statuses: C on blue background – Abstracting Complete – I on blue background – Abstracting Incomplete – C on green background – Coding Complete – I on green background – Coding Incomplete – I on green background– Compliance Held – V on blue background – Compliance Reviewed – NOTE: Compliance statuses only appear if Compliance integrations is set to Self-Review. See Compliance User Guide for more information.

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Creating a New Patient Encounter The process for creating a new patient encounter depends on whether Coding or Abstracting is attached to your facility’s host system. If you are not sure, ask your System Administrator.

1. Select Coding/Abstracting\View Encounters to open the list view of the View Encounters page.

Figure 126: View Encounters Screen

2. To enter a new facility encounter, click the Add New Facility Encounter button or the Code Books button. NOTE: The Code Books button is enabled for users with Add or View Coding permissions only. 3. Enter the patient information. See Entering Patient Encounter Information.

4. Enter the Coding information. See Code Modifiers.

5. Enter any additional Procedural information. See Entering Additional Procedure Information.

6. Enter any supplementary notes. See Enter Encounter Notes.

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Opening an Existing Patient Encounter

How to ...

 Open an Encounter for a Patient Already in the Database (see page 180)

 Open an Encounter from the Interlink Interface (see page 181)

Open an Encounter for a Patient Already in the Database

1. Select Coding/Abstracting to access the search view of the View Encounters screen.

2. Select a search criteria from the search drop-down list and press Go.

 You do not need to enter a search item in the blank search field. However, doing so focuses your search and returns a shorter list.

 If you know the account number of the encounter, enter it in the search field. When you click Go, the screen for that encounter opens.

 Your search criteria are saved on this screen, either until you log out of the session or re-set the criteria.

3. The list view of the View Encounters screen displays a list of encounters which match your search criterion:

Figure 127: View Encounters Screen

4. Click the encounter you want to edit.

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Open an Encounter from the Interlink Interface

NOTE: Your System Administrator can tell you the correct keyboard action, particular to your site, for launching Coding/Abstracting.

1. Open the record on the Interlink system.

2. Bring up Coding/Abstracting by performing the necessary keyboard action (which is an icon to click or a particular keystroke). Coding/Abstracting opens with the appropriate patient information filled in.

Entering Patient Encounter Information When you select a patient to review, that patient’s Coding screen appears. On this screen, you can verify the patient’s information:

Payor DRG Save button Edit Patient Cancel button ICD-10 DRG label Version Details icon

Figure 128: Coding Screen - Patient Information Banner

Click Edit Patient Details icon to update/add patient information.

In the four sections on the screen, you can make changes to the fields.

 Demographic Information (see page 182)

 Administrative Information (see page 182)

 Visit Characteristics (see page 182)

 Financial Information (see page 183)

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Demographic Information

Table 56: Demographic Information Fields and Descriptions

FIELD DESCRIPTION

Last Name Patient’s last name. The information in this field cannot be edited.

First Name/MI Patient’s last name and middle initial. The information in this field cannot be edited.

Sex Patient’s sex. The information in this field cannot be edited.

DOB Patient’s date of birth. The information in this field cannot be edited.

Age Patient’s age. The information in this field cannot be edited.

Birth Weight Patient’s birth weight. The information in this field cannot be edited unless the patient is less than 29 days old. (For Inpatient and Outpatient patient types only.)

Administrative Information

Table 57: Administrative Information Fields and Descriptions

FIELD DESCRIPTION

Bill Type The bill type for the encounter. Inpatient and Outpatient  Click the lookup icon to open a pop-up window where you can select bill types. patient types only  Sometime the bill type contains more words than can be seen in the field. To see all the words, place your cursor focus in the field and drag your mouse to the right.

Patient Type Select a patient type from the drop-down list.

Visit Type Select a visit type from the drop-down list.

Coder The name or initials of the coder who coded the encounter.

Visit Characteristics

Table 58: Visit Characteristics Fields and Descriptions

FIELD DESCRIPTION

Account # Patient account number.

If you need to change this, click the lookup button to access a screen where you can select an account number.

MRN Medical record number.

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FIELD DESCRIPTION

Admit Date The time and date the patient was admitted for this encounter. This date is in the format HH:MM:SS MM/DD/YYYY. The hour is in 24-hour format. If not given, the time is assumed to be 00:00:00. This cannot be a future date.

Discharge Date The time and date the patient was discharged after completion of this encounter. This date is in the format HH:MM:SS MM/DD/YYYY. The hour is in 24-hour format. If not given, the time is assumed to be 00:00:00. This can be a future date as well. NOTE: The Discharge Date field is left blank when an encounter has a discharge status set to 30.

LOS The Length of Stay for the encounter.

Discharge Status If you need to change the patient’s discharge status, click the lookup button to access a screen where you can select a discharge status.

Attending Provider If you do not know the provider’s ID, click the lookup button to access a screen where you can select a provider.

 Select search criteria from the drop-down list and enter the item you are searching for in the Search field.

 Click a provider’s link; you are automatically returned to the Patient Information screen.

Referring Provider If you do not know the provider’s ID, click the lookup button to access a screen where you can select a provider. Only in Physician Coding  Select search criteria from the drop-down list and enter the item you are searching for in the Search field.

 Click a provider’s link; you are automatically returned to the Patient Information screen.

Financial Information

Table 59: Financial Information Fields and Descriptions

FIELD DESCRIPTION

Primary Payor ID From the drop-down list, select the ID of the party that has primary financial responsibility for the encounter. NOTE:

 You can access both ICD-9 and ICD-10 inpatient and outpatient encounters even without entering any Payor ID (both primary and secondary) in the Patient Information screen.

 For all encounters with a Date after 10/1/2014, if both the Primary Payor ID and the Secondary Payor ID fields are left blank, then the Coding (P) and Procedural Info (P) screens display ICD-10 data and the Coding (S) and Procedural Info (S) screens display ICD-9 data.

Secondary Payor ID From the drop-down list, select the ID of the party that has secondary financial responsibility for the encounter from the drop-down list.

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FIELD DESCRIPTION

Total Charges The total financial charges for the encounter. Inpatient and Outpatient patient types only

If Coding/Abstracting is interfaced to your hospital's information system through a network, much of this screen might already be filled out when you open the patient's record.

Icons from the Coding Screen There are icons on the Coding screen, discussed here.

How to ...

 Enter Encounter Notes (see page 185)

 View Encounter History (see page 187)

 Copy Codes (see page 188)

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Enter Encounter Notes Notes for encounters enables you to include additional information on an encounter. An important feature of the Notes page is that it provides a text area of up to 2,000 characters, for more than one type of note.

If you do not have permission to edit all user notes, you can:

 Create notes under your own user name.

 Modify notes created under your user name.

However, you cannot select a date on a new note or modify the date on an existing note.

If you do have permission to edit all user notes, you can:

 Create notes under your own and someone else’s user name.

 Modify notes created under your user name or someone else’s user name.

 Select or change the date on a new and existing notes.

1. From Coding\View Encounters, select an encounter to open the Coding screen.

Notes icon

Figure 129: Coding Screen - Notes Icon

2. Click the Notes icon. The Notes pop-up window displays.

3. Choose a type of note from the first drop-down list at the left. The available types are:

Table 60: Encounter Notes Fields and Descriptions

FIELD DESCRIPTION

General For notes you want to print on Coding forms. Does not print on any reports but is accessible through JReports. NOTE: It is available only if you have license and permissions to CDI and Workflow.

Pull List These notes print on the daily Pull List.

Outguide These notes print on the Outguide for the record.

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FIELD DESCRIPTION

PA Worksheet These notes print on the Inpatient or Outpatient Post Audit Worksheet, (based on patient type of the encounter).

CoCo Used to send notes between Facility Coding and IP and OP Compliance.

When you click the Send check box, the system sends the note when the coding encounter is completed, provided the facility has self-review or auto-populate review turned on for the specific visit type. (For details on permission settings, see System Administration Guide.)

Physician Query These notes display on the Encounter pages and print on the Physician Query Form.

Billing Form These notes print on Billing Form created by Coding.

Optional 1 & Optional 2 For use with interfaces.

CDI Note These notes print CDI information. NOTE: It is available only if you have license and permissions to CDI.

The creator name field defaults to the current user.

Figure 130: View Encounters Notes Window

4. Enter the date for the note, or click the Calendar icon to select the date from a calendar.

5. Enter the text of the note in the large text field. Your note can be up to 2,048 characters.

6. To add additional notes, click the Plus icon to the right of the text field. ( )

NOTE: When the note is added, a green check-mark is displayed with the Notes icon ( ).

7. To remove notes, click the Trash can icon to the right of the text field. ( )

NOTE: The Notes are saved to:

 The session when you close the Notes pop-up window.

 The encounter only when you save the encounter with Save .

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View Encounter History When you are viewing an encounter, you can look at the encounter history.

1. Click the History icon on an encounter to open the History pop-up window.( )

Figure 131: Encounter History Lookup Window This screen shows the following information, which is not editable:

Table 61: Encounter History Lookup Fields and Descriptions

FIELD DESCRIPTION

User ID The person who entered the data. Click header to sort the list by users.

Activity The activity performed in the encounter.

Date and Time The date and time that the activity was performed. Click header to sort the list chronologically.

2. Click the print icon to print a copy of the history information.( )

3. Click the Close button to close the Encounter History Lookup window.

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Copy Codes If you are entering multiple encounters for a patient, you can copy codes from a previously coded encounter for the same patient at the same facility.

1. Follow the steps to enter patient information in Entering Patient Encounter Information on page 181.

2. Select an encounter from the View Encounters screen to open the Coding screen.

3. Click the Copy Codes icon in the Codes panel to open the Copy Codes Select Encounter(s) screen. ( )

Figure 132: Copy Codes Window

4. Check the checkbox next to the encounter(s) you want to view in more detail.

5. Click View Codes.

6. The Copy Codes Select Encounter(s) screen lists the selected encounter’s codes. If you chose more than one encounter, all of the encounters are listed on one screen.

Figure 133: Copy Codes from Related Encounter(s) Window

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7. You can:

 Add the codes to the encounter by checking the checkbox next to the code(s) you want to add to the encounter. If a checkbox is grayed out, you cannot add that code to the encounter. Click Add Codes. The codes are added to the encounter and the pop-up window closes.

 Click Back to return to the list of encounters.

 Click Cancel to close the pop-up window without adding any codes to the encounter.

NOTE: The Copy Codes icon is active when the patient has other encounters within the same facility (inpatient, outpatient, or physician). The link also remains active during the coding session of an open encounter. You can access the link as often as necessary during the coding session.

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Managing Electronic Documents Direct integration with the EDM HIM module greatly enhances productivity while providing added flexibility to hospitals in support of remote coding. If your facility has purchased and implemented Electronic Document Management, you work with it within Coding/Abstracting. (For detailed instructions on using EDM, see the Electronic Document Management User Guide.)

NOTE:

 Your monitor resolution must be 1600X1200 in order to view both the Clintegrity screen and the EDM document at the same time.

 For integration to work, you must set the Document Types in Clintegrity Electronic Document\Setup\Doc Security & Settings.

How to ...

 Access Electronic Documents (see page 190)

 Work With Electronic Documents (see page 191)

Access Electronic Documents

1. Within an existing encounter click the Documents icon to launch the EDM document viewer. ( ) EDM searches for the matching facility or patient and encounter, then pops up a document viewer window with an index for all of the selected encounter’s documents. You can now work on the document within EDM.

Click to open list of available document. Click the Print icon to print The default the document. document for the visit type opens.

Figure 134: Document View Screen

See Set Up User Preferences on page 47 for information on setting default types.

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Work With Electronic Documents

1. Access the relevant document on EDM (see Access Electronic Documents on page 190).

2. You can work between the two screens–Coding and EDM. While working on the EDM page you can:

 Save Layout – Click the Save Layout button, at the bottom of the page, to retain both the size and position of the document viewer window. The window stays as set each time that you access a document. To change the setting, resize or move the document viewer, then click Save Layout to establish the new setting.

 Expand the Document List – Click the Document List + node to expand the list of documents pertinent to this request. Click the name of any document in list, and that document opens.

Figure 135: Document View List Window

 Print a document with annotations by either:  While viewing it, clicking the Printer icon on the tools palette.  Checking the box to the left of the document’s name in the Document List, then click the Printer icon on the tools palette. You can check several documents to print.

 Close the EDM document viewer by either:  Navigating away from the Coding page from which you opened it.  Closing the Coding window while the document viewer is open; both close.  Clicking the Close button at the bottom of the EDM document viewer.

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Completing the Coding Process on Encounters When you have finished coding an encounter, you can proceed to complete the coding process.

How to ...

 Save an Encounter (see page 192)

 Export Encounters (see page 193)

 Delete Encounters (see page 195)

Save an Encounter When you are finished with a patient encounter, you need a way to tell your host system or billing system that the record is ready for processing.

CAUTION: For many systems, once a coded record is sent to a host system (by clicking the Save button) the record is done. You might not be able to change it after that. What you can change depends on your facility's Coding/Abstracting installation. Check with your System Administrator to see what you can and cannot do.

When you finish entering the encounter, you can:

 Click Cancel to discard your changes.

 Click the Save button to save the encounter as complete. NOTE: This feature is only available for users that do not have Abstracting license.

 Click the drop-down next to the Save button to select the coding status. The Save drop-down has the following options in the list.

 Save As Incomplete – Encounter needs further corrections or work.

 Save As Complete – Encounter can be validated.

 Save As – Encounter needs more information to be complete.

The encounter is validated for incomplete information and coding errors. If there are critical coding errors, you need to correct them before the encounter can be considered complete. See Using the Editor on page 303.

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Export Encounters When you finish coding encounters, you can send them and their statuses to an output file. The Export function enables you to choose the file format most appropriate for your system.

To schedule a batch encounter export, see Batch Export Scheduler on page 134.

1. Select Coding/Abstracting\Setup\Export to access the Export screen.

Select the File Layout

Preview Button Export Button

Figure 136: Export Encounters Screen

2. Choose the facility for which to export encounters. If you are exporting OSHPD data from Abstracting, you can select only one facility per time period.

3. Select the export file layout from the File Layout drop-down list. When exporting a single encounter, choose the x_Coding_XML_Format.xml file layout.

NOTE: Both ICD-9 and ICD-10 codes are exported using the following ICD-10 file layouts: d_Coding_Default_Facility_DelimitedAscii_ICD10.xml and f_Coding_Default_Facility_FixedAscii_ICD10.xml

4. Enter the Export File Name.

5. Select the Patient Type to export by checking the appropriate checkbox. More that one patient type can be exported at one time (except if you are exporting OSHPD data from Abstracting; only Inpatient type is available.)

6. Enter the appropriate dates—Admit Date Range, Discharge Date Range and Last Modified Date Range— in the format MM/DD/YYYY. The dates can be entered directly, or click the Calendar icon to choose them from a calendar. If you want to export a specific encounter, enter the account number for the encounter in the Account Number field. The account number needs to be an exact match, including the leading zeros.

For information on looking up the encounter account number see, Advanced Search for Encounter.

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7. Click Save by selecting a Coding Status from the Save drop-down list.

8. Click the Compliance Status Released checkbox to export only those coding encounters which satisfy the applied filter conditions and which also have an additional filter of a compliance release status. If you leave it unchecked, all the coding encounters which satisfy the applied filter conditions are exported, irrespective of their compliance release status.

NOTE: You can also check or uncheck this option by using the SPACEBAR.

9. Click the Preview button to preview the file before you export it. Up to 30 encounters are listed on the preview screen.

Figure 137: Export Preview Screen

10. Click Close to return to the Export screen.

11. Click the Export button to export the file.

 The Export Loading screen appears and displays a status bar which shows the progress of the export file.

 When the export file operation is complete, the Export Results screen appears confirming the success of the operation, the number of encounters exported, and the directory location of the export file on the server.

NOTE:

 The ICD-10 file layouts support exporting both ICD-9 and ICD-10 information.

 You must have the ICD-10 Coding license to create ICD-10 File Layouts and then export them.

 The Maintain Coding And Compliance permission in the Coding/Abstracting Settings section must be selected under Admin\Users/Security\Manage Groups\Coding/Abstracting.

 You can use Batch Export Scheduler or Batch Import Scheduler to set up export or import scheduler respectively with ICD-10 file layout.

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Deleting Encounters Encounters can be deleted by encounter criteria from Coding/Abstracting.

How to ...

Delete Encounters

1. Go to Coding\Setup and select Delete Encounters. The Deletion Criteria section is displayed.

Figure 138: Delete Encounters Screen in Coding

2. Enter appropriate criteria in the fields. Refer Delete Encounters Fields and Descriptions in Coding.

3. Click the Preview button to see information about the encounter(s) being deleted. Up to 20 encounters are listed on the preview screen.

4. Click the Close button to close the Preview.

5. Click the Delete button, the warning message is displayed:

Figure 139: Warning Message

NOTE: Workitems associated with the encounter in the Workflow module will also be deleted along with the encounter.

6. Click the Delete button again to delete the encounter, from the coding module and

Table 62: Delete Encounters Fields and Descriptions in Coding

FIELD DESCRIPTION

First Name The patient’s first name.

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FIELD DESCRIPTION

Last Name The patient’s last name.

Account # The patient’s account number.

MRN The patient’s Medical Record Number.

Facilities Facility that encounter is assigned to.

Coding Status Status of that encounter.

DOS Range Date of Service range for encounters.

Patient Types Patient type for encounter.

Standard Forms You can view a list of standard forms in Coding/Abstracting by clicking the Forms icon on the coding screen. The forms display based on the license, permissions, and relevance to the selected encounter. ( )

NOTE: For more information on keywords of all standard forms, see Keywords for Standard and Custom Forms (see page 363)

Figure 140: Forms Window

Click the Preview or Print icon to view or print the selected form from the list.

NOTE:

 For more information on printing a form, see Print the Form on page 198.

 All Custom forms are displayed below the Standard forms in the list.

Creating and Printing Forms You can create customized forms in Coding/Abstracting. This section discusses:

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How to ...

 Create a Custom Form (see page 198)

 Print the Form (see page 198)

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Create a Custom Form NUANCE recommends using Microsoft Word as your form template writer. While any word processing or text processing software can be used, Microsoft Word 2003 provides the best laid out results.

1. Create a form as you would any other document. Save it as an.html file. You can use the standard documents at Quantim/topazapp/letters/Coding as templates for your custom letters. Save all custom letters under a different names than the original standard form, to avoid having them overwritten when you upgrade your Clintegrity application.

2. Insert keywords as needed.

 Each keyword must be entered in the form in which it appears in the list of Standard Forms and Keywords: on page 363— in all capital letters and surrounded by braces {}.

 If two keywords are the same line but at opposite margins, you must insert a table that spans the width of the page, with no cell borders, in which to place the keywords.

3. Save the form in.html format in the Quantim/topazapp/letters/Coding directory. 4. If you want to use an image in the letter, copy the image directory that is created when you save the letter to the Tomcat/Webapps/Topaz/Temp directory. 5. Restart Clintegrity to have the system access and use the new form.

Print the Form You can print a standard or custom form from the Coding screen.

1. While you are reviewing or creating a form, click the Forms icon on the Coding screen. ( ) The Forms window with the forms list displays.

NOTE: All Custom forms are displayed below the Standard forms in the list.

2. Click the Preview icon to launch a preview of the form populated with the Coding information. ( ) On the preview page, click Print if you want to print the form out. The print dialog box appears so that you can select a printer and print the form.

3. Click the Print icon to print the form without previewing it. ( ) Due to tightened security in Internet Explorer, your browser might return a warning when you attempt to print a Coding form. If this happened, you can do either of the following:

 Click the Preview icon and then click Print from the preview screen. The form prints. or

 Adjust your browser security settings as follows:  Open Tools\Internet Options\Security.  Select the Local Network icon, then click the Sites button.  Click the Advanced button, then type in the IP address of your Clintegrity server (such as 192.168.10.40) and save it.  Return to the Coding screen, click Print and the form prints.

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Chapter 7 Using the Code Books

NOTE:

 Current Procedural Terminology (CPT) is copyright 2018 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

 NUANCE recommends that clients keep a hard copy of the current ICD and CPT code books at their facility. Clients should also maintain or subscribe directly to industry standard references such as, but not limited to, AHA Coding Clinic, AMA CPT Assistant and Medical Dictionaries. The references contained in Clintegrity are intended to be tools to assist the coder while using the application, but they are not intended to replace the original publications.

Most of the work you do with Coding/Abstracting involves using code books, to fill out an encounter codelist. This section discusses the Code Books, under the following topics:

 Overview of Code Books (see page 200)

 Features on Alphabetic Indexes, ICD-10 PCS Tables, and Tabular Lists (see page 201)

 Working with ICD-10 CM Code Book (see page 220)

 Working with ICD-10 PCS Code Book (see page 226)

 Using Standard Search in ICD-10 CM and PCS Code Books (see page 229)

 Using Smart Search in ICD-10 CM and PCS Code Books (see page 231)

 Using the Indexes (see page 237)

 Using the Tabulars (see page 240)

 Working in Code Books (see page 244)

 Using Context Menu in Codebooks (see page 258)

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Overview of Code Books Clintegrity comes with several electronic code books that you might recognize from their paper counterparts:

Table 63: Code Books and Descriptions

BOOK DESCRIPTION

Dx Book ICD-9 CM Alphabetical Index of Diseases and Injuries that is cross-referenced to and hyperlinked to the Tabular List of Diseases and Injuries. Includes the Hypertension Table, Neoplasm Table, Table of Drugs and Chemicals, Supplementary Classification of Factors Influencing Health Status and Contact With Health Services, and access to the classification appendices.

Px Book ICD-9 CM Alphabetical Index of Procedures that is cross-referenced to and hyperlinked to the Tabular List of Procedures. Includes access to the classification appendices.

E-Code Book ICD-9 CM Alphabetical Index of External Causes and Poisonings that is  cross-referenced to and hyperlinked to the Tabular List of Supplementary Classification of External Causes and Poisonings. Includes access to the classification appendices.

CPT Book Current Procedural Terminology is a listing of descriptive terms and identifying codes. The CPT Alphabetic Index is not a substitute for the main text (Tabular), which is organized by code number, but provides the ability to locate a code(s). The Index is cross-referenced to and hyperlinked to the Tabular List of codes. Includes access to the CPT appendices.

HCPCS Book Healthcare Common Procedure Coding System is an alphanumeric listing of service and supply codes. The HCPCS Alphabetic Index provides the ability to locate codes. The Index is cross-referenced to and hyperlinked to the Tabular List of codes.

CM Book ICD-10 CM Alphabetical Index of Diseases and Injuries that is cross-referenced to and hyperlinked to the Tabular List of Diseases and Injuries. Includes the Neoplasm Table, Table of Drugs and Chemicals, External Causes of Morbidity, and Factors Influencing Health Status, and Contact With Health Services. All codes are alphanumeric.

PCS Book ICD-10 PCS (Procedure Coding System) Alphabetical Index of Procedures that is cross-referenced to and hyperlinked to the specific Table. The Tables are utilized to complete the code or they may be accessed directly to build a code without referring to the index. Includes access to the Procedure Coding System references (definitions).

NOTE: Three years (current year and previous two years) of all the codebooks are maintained in Clintegrity, along with a mapping feature to facilitate direct lookup of codes.

The Code Books pop-up window displays when you click the Code Books icon ( )

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The electronic code books have several advantages over their paper counterparts:

 All the code books work similarly. You move through them in the same way and search for entries using the same methods.

 You can link from term to term, or book to book using items on the pop-up menu.

 These are cross references that you can right-click to view references context menu. Click appropriate reference to go to the References window.

Code Books cross references References context menu

Figure 141: Code Books to References

 You can search for words or parts of a word in the Alphabetic indexes and for codes in the Tabulars Lists or PCS Table.

Features on Alphabetic Indexes, ICD-10 PCS Tables, and Tabular Lists One of the advantages to Clintegrity Code Books is that all of the books work in similar ways. This section discusses common features and functions of the Alphabetic Indexes, PCS Tables, and Tabular Lists:

 Visual Overview of Indexes (see page 202)

 Visual Overview of the Tabulars Lists and PCS Table (see page 206)

 Selection in the Indexes, Tables, and PCS Tables (see page 212)

 Navigating In the Index and Tabular (see page 216)

 Tabular Details (see page 217)

 Cross References (see page 219)

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Visual Overview of Indexes The ICD-9, ICD-10 CM, HCPCS, and CPT Alphabetic Indexes have the same features. The following is a screen of the ICD-9 CM Diagnosis Index:

Search Text Box

Main Term

Context Area

Selected Area

Figure 142: ICD-9 CM Diagnosis Index Screen

The following is a screen of the ICD-9 CM Diagnosis Index displaying an index entry that has been added to the index. These lines which are included in each of the various indexes, use the QLine symbol to communicate that this entry is not included in the official index but added to aid in the index search functionality and code assignment. ( )

Figure 143: ICD-9 CM Diagnosis Index Search Screen

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The following is a screen of the ICD-9 CM Procedure Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 144: ICD-9 CM Procedure Index Screen

The following is a screen of the E-Code Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 145: E-Code Index Screen

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The following is a screen of the CPT Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 146: CPT Index Screen

The following is a screen of the HCPCS Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 147: HCPCS Index Screen

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The following is a screen of the ICD-10 CM Diagnosis Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 148: ICD-10 CM Diagnosis Index Screen

The following is a screen of the ICD-10 PCS Procedure Index:

Search Text Box

Main Term

Context Area

Selected Term

Figure 149: ICD-10 PCS Procedure Index Screen

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Visual Overview of the Tabulars Lists and PCS Table The ICD-9 CM, ICD-10 CM, HCPCS, and CPT Tabular List have the same features. A Table format is utilized in ICD-10 PCS instead of a Tabular List.

The following is a screen of the ICD-9 CM Diagnosis Tabular with codes listed in numeric sequence:

Search Text Box

Context area Symbols used in the tabular

Body of tabular

Expand Lists

Figure 150: ICD-9 CM Diagnosis Tabular List Screen (Standalone)

Context area

Selected Term

Expand Lists

Body of tabular

Symbols used in the Tabular

Figure 151: ICD-9 CM Diagnosis Tabular List Screen (Embedded)

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The following is a screen of the ICD-9 CM Procedure Tabular with codes listed in numeric sequence:

Search Text Box

Context area

Selected Term

Expand Lists

Body of tabular

Symbols Used in the Tabulars

Figure 152: ICD-9 CM Procedure Tabular List Screen (Standalone)

Figure 153: ICD-9 CM Procedure Tabular List Screen (Embedded)

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The following is a screen of the CPT Procedure Tabular with codes listed in numeric sequence:

Figure 154: CPT Procedure Tabular List Screen (Standalone)

Figure 155: CPT Procedure Tabular List Screen (Embedded)

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The following is a screen of the ICD-10 CM Diagnosis Tabular with codes listed in numeric sequence:

CC and MCC flags

Figure 156: ICD-10 CM Diagnosis Tabular List Screen (Standalone)

Figure 157: ICD-10 CM Diagnosis Tabular List Screen (Embedded)

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The following is a screen of the HCPCS Tabular with codes listed in alphanumeric sequence:

Figure 158: HCPCS Tabular Screen (Standalone)

Figure 159: HCPCS Tabular Screen (Embedded)

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The following is a screen of the ICD-10 PCS Table that is used to build a complete code:

Figure 160: ICD-10 PCS Table Screen (Standalone)

Figure 161: ICD-10 PCS Table Screen (Embedded)

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Selection in the Indexes, Tables, and PCS Tables

Diagnoses and Procedures When searching for a term, Clintegrity automatically selects the term that most closely matches your search criteria.

Using ICD-9 CM Alphabetical Index and Tabular List as examples, the selected focused entry is highlighted in green. The selected entry is the entry that reacts to commands you choose. For instance, if a term is selected in an index and you click the code associated with the term, you are taken to that code in the Tabular List.

Figure 162: Index and Tabular List Screen

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Selected entry with subterms display the main terms or additional subterms to show the indexing indentation of the entry. This appears in the yellow Context Area.

Figure 163: Index and Tabular List Screen

Selected focus displays in green in the Tabular List with the Context Area displaying the preceding classification code categories.

Figure 164: Index and Tabular List Screen

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Search the procedure term nephrectomy. Click the partial code 0TT to open the root operation Resection for the Urinary System.

Figure 165: ICD-10 PCS Search Terms Screen

The corresponding PCS Table 0TT for Root Operation Resection of kidney is opened.

Figure 166: ICD-10 PCS Table Screen

Using the Table functionality build the full code selecting with a click characters 4-7 left to right in the same row to complete the code. When there is no choice but one in the subsequent columns, the character is automatically selected for you.

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Character 4

Figure 167: 4th Character Selection in ICD-10 PCS Search Results - Example

NOTE: The auto-select functionality will not be available on the 4th character (4th column) when there are duplicate rows.

Character 5-7. Notice that the seven character descriptions display in the Context Area as the code is built.

Figure 168: 5-7 Character Selection in ICD-10 PCS Search Results - Example

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Navigating In the Index and Tabular

How to ...

Move Around in the Index and Tabular You move around in the Index and Tabular in standard Windows-based fashion.

 To establish focus in the body of the index or tabular, click in the body or press TAB.

 Use these keystrokes to move around the index or tabular:

Table 64: Index and Tabular Keystrokes and Descriptions

KEYSTROKE DESCRIPTION

DOWN KEY Down one line

UP ARROW KEY Up one line

SHIFT+DOWN ARROW KEY Down one term at same hierarchical level

SHIFT+UP ARROW KEY Up one term at same hierarchical level

LEFT ARROW KEY Out one hierarchical level

RIGHT ARROW KEY In one hierarchical level

PAGE UP KEY To the next screen of terms

PAGE DOWN KEY To the previous screen of terms

CTRL+ LEFT ARROW KEY To navigate back to the index

 Right-click an item for the context menu. See Using Context Menu in the Codes Panel for more information.

 Click the scroll buttons to move up or down one line at a time.

 Click the paging areas of the scroll bar to move up or down a page at a time.

 Drag the scroll bar to move further up or down the list.

 Click the Back to Index link to return to index.

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Tabular Details Tabular Details are additional information contained in the tabulars to help you select the right code. The ICD-9 CM, ICD-10 CM, and CPT tabulars have details. Often, codes listed in Tabular Details are hyperlinked to make it easy for you to link to a suggested code.

The ICD-9 CM Tabular Details contain the following types of information:

Table 65: ICD-9 CM Tabular Fields and Descriptions

FIELD DESCRIPTION

Note Explanatory text in the books at the beginning of a Tabular section or before a range of codes.

Includes This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

Excludes An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together. In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present.

Inclusion Terms List of terms is included under certain four and five character codes. These terms are the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the index may also be assigned to a code.

Code First and Use Additional Providing sequencing direction, these notes indicate that certain conditions Code have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The underlying condition is sequenced first followed by the manifestation. The Use Additional Code note is at the etiology code, and a Code First note at the manifestation code.

Code Also A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

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The ICD-10-CM Tabular Details contain the following types of information:

Table 66: ICD-10 CM Tabular Fields and Descriptions

FIELD DESCRIPTION

Note Explanatory text in the books at the beginning of a Tabular section or before a range of codes.

Includes This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

Excludes1 A type 1 Excludes note is a pure excludes note. It means Not coded here.  An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions can not occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2 A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Inclusion Terms List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

Code First & Use Additional Providing sequencing direction, these notes indicate that certain conditions Code have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The underlying condition is sequenced first followed by the manifestation. The Use Additional Code note is at the etiology code, and a Code First note at the manifestation code.

Code Also A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

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The CPT Tabular Details contain the following types of information:

Table 67: CPT Tabular Fields and Descriptions

FIELD DESCRIPTION

Notices Parenthetical comments that appear with individual CPT codes in the printed books.

Notes Notes that appear at the beginning of CPT tabular subsections - covering a range of codes.

Mods Modifiers listed in the Guidelines text that appears at the beginning of each section in the printed books.

Guides The rest of the Guidelines text, excluding the Modifiers section, which appears under Mods.

NOTE: You must be working in an encounter to access the CPT code book information

See Acting on Entries You Find in the Tabulars for information on Tabular Details.

Cross References Some of the terms in an index provide cross references to other terms. Cross references are denoted by the words see or see also next to the term. They are also hyperlinks, meaning you can quickly link to the reference by clicking the blue text.

Figure 169: Cross References in Code Book Search Results

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Working with ICD-10 CM Code Book This section discusses the various search features available in the ICD-10 CM Code Book.

How to ...

 Use the Find All-Index Search (see page 220)

 Use the Find All-Tabular Search (see page 221)

 Using Standard Search in ICD-10 CM and PCS Code Books (see page 229)

 Using Smart Search in ICD-10 CM and PCS Code Books (see page 231)

Use the Find All-Index Search The Find All-Index Search is used to search for a term or code existing on an index line.

1. Select Find All-Index from the drop-down list in the upper right-hand corner of the Code Books window.

2. In the Search text box, type the word or words you want to find, or type the first few letters of the word (for example, type hyper for hypertrophy). You can enter multiple words separated by commas or spaces.

3. Press ENTER or click Go. All index lines containing the search term(s) are displayed in alphabetical order. If there are more than 250 results, the first 250 are displayed with a message: Add additional terms to limit your search. The first 250 results have been displayed.

Figure 170: Find All-Index Search Screen (Standalone)

220 Chapter 7 Using the Code Books

4. Click the term that you want to see. The corresponding Index line location in the ICD-10 CM code book is displayed.

Figure 171: Index Line Location in the ICD-10 CM Code Book

5. Manually enter the code in the Codes panel.

Use the Find All-Tabular Search The Find All-Tabular Search is used to search for one or more terms or codes in the Tabular.

1. Select Find All-Tabular from the drop-down list in the upper right-hand corner of the Code Books window.

2. In the Search text box, type the word or words you want to find, or type the first few letters of the word (for example, type hyper for hypertrophy). You can enter multiple words separated by commas or spaces.

3. Press ENTER or click Go. All Tabular/Table lines containing the search term(s) are displayed numerically. If there are more than 250 results, the first 250 are displayed with a message: Add additional terms to limit your search. The first 250 results have been displayed.

Figure 172: Find All-Tabular Search

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4. Click the term that you want to see. The corresponding Tabular line location in the ICD-10 CM code book is displayed.

Figure 173: Tabular Line Location in the ICD-10 CM Code Book

5. Right-click on the code to view the References context menu The References screen is displayed with description for the corresponding code.

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Tables in the ICD-10 CM Diagnosis Index

How to ...

 View an Entry in the Neoplasm Table (see page 223)

 View an Entry in the Drugs and Chemical Table (see page 224)

View an Entry in the Neoplasm Table

1. In the Search text box, type -(dash), neoplasm site. For example: - intestine.

Table 68: Table Search Terms and Descriptions

SEARCH TERM DESCRIPTION

rx- Drugs

ca- Neoplasm Tables

2. Press ENTER or click Go. The Neoplasm Table opens with a box around the site you specified.

Figure 174: Neoplasm Table

3. Codes appear under the column headings Primary, Secondary, Ca In Situ, Benign, Uncertain Behavior, and Unspecified.

4. From this screen, you can do the following:

 Move from one code to the next in the highlighted line by clicking the code.

 Go to the tabular entry for a code by clicking it or pressing the ENTER key.

5. On the tabular, review the code and manually add to the Codes panel.

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View an Entry in the Drugs and Chemical Table

1. In the Search text box, type tabl or table, Drug or Chemical Name. For example: tabl Coumadin.

2. Press ENTER or click Go. The Table of Drugs and Chemicals appears, with a box around the entry for the drug or chemical you specified.

Figure 175: Drugs and Chemicals Table Codes appear under the following column heads:

 Poisoning, Accidental (unintentional)

 Poisoning, Intentional Self-harm

 Poisoning, Assault

 Poisoning, Undetermined

 Adverse Effect

 Underdosing

3. From this screen, you can do the following:

 Move from one code to the next in the highlighted line by pressing TAB.

 Go to the tabular entry for a code by clicking it or pressing the ENTER key.

 Use TAB to move across the table to a new code. Click the code or press ENTER to move to the Tabular.

4. Manually enter the code in the Code list.

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View an Entry in the External Cause Index

1. In the Search text box, type ex- followed by the external cause main term. For example: ex-fall

2.E Press NTER or click Go. The External Cause Index appears, with a box around the entry for the specified external cause.

Figure 176: External Cause Index Page

3. From this screen, you can do the following:

 Move from one code to the next in the highlighted line by pressing TAB.

 Go to the tabular entry for a code by clicking it or pressing the ENTER key.

4. Manually enter the code in the code list.

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Working with ICD-10 PCS Code Book This section discusses the various search features available in the PCS Code Book.

How to ...

 Use the Find All-Index Search (see page 226)

 Use the Table Search (see page 228)

 Using Standard Search in ICD-10 CM and PCS Code Books (see page 229)

 Using Smart Search in ICD-10 CM and PCS Code Books (see page 231)

Use the Find All-Index Search The Find All-Index Search is used to search for a term or code existing on an index line.

1. Select Find All-Index from the drop-down list in the upper right-hand corner of the code book screen.

2. In the Search text box, type the word or words you want to find, or type the first few letters of the word (for example, type colon). You can enter multiple words separated by commas or spaces.

3. Press ENTER or click Go. All Index lines containing the search term(s) are displayed alphabetically. If there are more than 250 results, the first 250 are displayed with a message: Add additional terms to limit your search. The first 250 results have been displayed.

Figure 177: Find All-Index Search

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4. Click the term Bypass; Colon; Descending, the index entry is opened displaying the green focus.

Figure 178: PCS Code Books Screen

5. Click the hyperlink partial code OD1M to open the corresponding PCS Table. Character 4 column Body Part is selected. Select characters 5, 6, and 7 moving the focus to the next column.

Figure 179: PCS Code Book Table

6. Manually enter the code in the code list.

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Use the Table Search

1. Select Table from the drop-down list in the upper right-hand corner of the code book screen.

2. In the Search Terms frame, select values from the following drop-down boxes:

 Section 1 -- select 0

 Character 2 -- select 2

 Character 3 -- select 1

3. Press ENTER or click Go. The corresponding Table location in the ICD-10 PCS code book is displayed.

Figure 180: ICD-10 PCS Code Book Table All the Character 4 column items are hyperlinked. Once you make an item selection from Character 4 column, the hyperlinks of the corresponding row of Character 5, 6, and 7 columns are highlighted. If there is only one option to be selected in the next column, the system will select it for you, moving the focus to the next column data that requires selection.

4. Manually enter the code in the code list.

NOTE: The code book search dialog does not display ICD-10 PCS code search for the Physician patient type.

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Using Standard Search in ICD-10 CM and PCS Code Books This section explains the powerful Standard search feature in the CM and PCS Code Books.

How to ...

 Search for a Main Term (see page 229)

 Search for Main Terms and Subterms at the Same Time (see page 229)

 Search for a Subterm After Locating a Main Term (see page 230)

All of the procedures in this section assume that you are in the Code Books section. Select Coding/ Abstracting\Code Books\CM or PCS Code Book to access the code book search.

Search for a Main Term

1. Select Standard search type from the drop-down list in the upper right-hand corner of the  Code Books window.

2. In the Search text box, type the main term you want to find, without worrying about upper or lower case. For instance, to find Degeneration, you can type Degeneration or degeneration or type the first few letters of the main term (degen).

3. Press ENTER or click Go. The Index body scrolls to place the main term at the top of the list and the main term is selected. The Context Area appears with the main term. Clintegrity finds the term that most closely matches the text you typed.

Search for Main Terms and Subterms at the Same Time

1. Select Standard search type from the drop-down list in the upper right-hand corner of the  Code Books window.

2. In the Search text box, type the main term followed by subterms separated by either commas or spaces. For example, to look for the main term Degeneration and its subterm brain and brain’s subterm senile, you could type degeneration,brain,senile, or degeneration brain senile. You can type as many subterms as you want, and you need to only type the first few letters of each term or subterm - enough so that the entry is unique. For example, to find Degeneration, brain, senile, you could type dege,bra,sen or dege bra sen.

NOTE: You can either leave spaces between the words, or enter commas between the words. Don’t uses commas and spaces, as you would if typing a standard sentence.

3. Press ENTER or click Go. The body of the index scrolls to place the subterm at the top of the list, and the subterm is selected. The Context Area appears with the main term and its subterms.

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Search for a Subterm After Locating a Main Term

1. Select Standard from the drop-down list in the upper right-hand corner of the Code Books window.

2. In the Search text box, leave the main term, and type a comma followed by the subterm or a space and the subterm. For example, to find the subterm brain after you found the main term Degeneration you could type brain or brain. You can type as many subterms as you want. You need to only type the first few letters of each term or subterm - enough so that the entry is unique. For example, to find brain, senile after finding Degeneration, type bra,sen or bra sen.

3. Press ENTER or click Go. The body of the index scrolls to place the subterm at the top of the list, and the subterm is selected. The Context Area appears with the main term and its subterms.

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Using Smart Search in ICD-10 CM and PCS Code Books This section explains the powerful Smart search feature in the ICD-10 CM and PCS Code Books.

Smart Search is an index line search that will produce real-time results after entering three characters as you type for corresponding index line results. The following are examples to perform ICD-10 CM search: The following is an example to perform ICD-10 CM search:

1. In Search field, type any three letters from the term to search and choose the term portion from the ten selections in the drop-down menu. The codebook index will display the information related to the selected term.

Figure 181: Term display in the drop-down

2. In Search field, type gas and choose the code portion from the ten selection in the drop-down menu. The codebook tabular will display for the code selected.

Figure 182: CM Code display in the drop-down

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Table 69: Shortcuts used to display Tables and External Cause Index

TABLE/INDEX SHORTCUT

Neoplasm Table ca-

neop

-

Drugs and Chemicals rx- Table tabl

drug

External Cause Index ex-

The following is an example to perform ICD-10 PCS search:

1. In Search field, type gas and choose the term portion from the ten selections in the drop-down menu. The codebook index will display the information related to the selected term.

Figure 183: Terms display in the drop-down for PCS codes

232 Chapter 7 Using the Code Books

2. In Search field, type the term and choose the code portion from the ten selection in the drop- down menu. The PCS table will display for the code selected.

Figure 184: Code display in the drop-down for PCS codes NOTE: For CM or PCS, main term and/or sub-terms can be entered in any order with or without commas or special characters.

Using Smart Search for PCS Synonyms The PCS Synonyms can also be searched using Smart Search. Smart Search can be used on partially entered code, full entered codes, and terms. For more information, refer to the examples in the section below.

Partial code search

1. Enter KUB in the PCS Search field. The drop-down displays the auto-suggested codes of the next characters in PCS Table.

Figure 185: Partial code entered in the PCS Search field

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2. Click on the Y portion in the drop-down to view the related table in the Codebook with highlights.

Figure 186: Codebook displaying the related table with highlights

3. If the ENTER key is pressed without selecting any options. The Codebook displays the BT04 table without highlights.

Figure 187: Codebook displaying BT04 table without highlights

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Full code search

1. Enter CPB in the PCS Search field. No results found text is displayed.

Figure 188: Full code entered in the PCS Search field

2. Press the ENTER key to view the PCS table with the searched full code.

Figure 189: Codebook displaying the searched full code in the PCS table

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Term search

1. Enter the term BKA in the PCS Search field. The drop-down displays auto-suggested codes for Detachment Leg Lower.

Figure 190: Term entered in the PCS Search field

2. Click on the term Detachment Leg Lower. The related Index is displayed in the Codebook section.

Figure 191: Codebook displaying the index related to the searched term

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Using the Indexes Although the contents of the ICD-9 and CPT indexes are similar to their printed counterparts, navigating them can be very different. For example, you can flip through the electronic indexes page by page looking for the term you want. However, you are provided with these powerful navigation tools that make your job much easier:

 Synonyms (see page 439)

 Navigating With Icons (see page 41)

All of the procedures in this section assume that you have already opened an index. In addition, all of the procedures apply to the ICD-9 Dx, E-Code, ICD-9 Px, CPT, and Level II indexes, unless otherwise specified.

Each term, or code, in the index (and tabular) has a right-click menu. Point your cursor at the term or code, right-click and the menu opens. See page 41 for more details.

NOTE: You must be working in an encounter to access the CPT code book information

Acting on Terms You Find in the Indexes

How to ...

 Link to the Term's Code in the Tabular (see page 237)

 Link to a Cross Reference (see page 237)

 View Additional Information for a Term (see page 237)

Link to the Term's Code in the Tabular In an index, click the code link or press ENTER. For more information, see Using the Tabulars.

Link to a Cross Reference From an index, click the reference in blue following the word see. The referenced term appears at the top of the body of the index.

View Additional Information for a Term

1. In an index, right-click the term and the context menu appears.

2. Click the link for the kind of information you want. You can choose from all the reference books included with Clintegrity. If a link is not available, it means that the reference books do not contain any information for the term you selected.

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Tables in the ICD-9 Diagnosis Index

How to ...

 View an Entry in the Hypertension Table (see page 238)

 View an Entry in the Neoplasm Table (see page 239)

 View an Entry in the Drugs and Chemical Table (see page 240)

View an Entry in the Hypertension Table

1. In the Search text box, type htn,subterm.

2. Press ENTER or click Go. The Hypertension Table appears with the subterm you selected:

Figure 192: Hypertension Search Table with Subterm The codes are situated under relevant column heads—Malignant, Benign, and Unspecified.

3. Press TAB to move from one code to another in the highlighted line. Press ENTER to go to the tabular entry for a code.

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View an Entry in the Neoplasm Table

1. In the Search text box, type neo followed by the body site of the neoplasm. For example type neo brain.

2. Press ENTER or click Go. The Neoplasm Table opens with a box around the site you chose.

Figure 193: Neoplasm Search Table Codes appear under the column heads Primary, Secondary, In Situ, Benign, Uncertain Behavior, and Unspecified.

3. From this screen, you can do the following:

 To move from one code to the next in the highlighted line, press TAB.

 To go to the tabular entry for a code, click it or press the ENTER key.

 Right-click the code to open the context menu to view relevant references.

 On the tabular, review the code and any instructional notes, and manually enter the code to the code list.

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View an Entry in the Drugs and Chemical Table

1. In the Search text box, type tabl,Drug_or_Chemical_Name.

2. Press ENTER or click Go. The Table of Drugs and Chemicals appears, with a box around the entry for the drug or chemical you specified:

Figure 194: Drugs and Chemicals Search Table

From this screen, you can:

 Code a Poison if the Poison code is a live hyperlink (based on Facility Preferences; see page 53), click the link to go to the Tabular. (This codes the Poison without generating an e- code.)

 Go to the tabular by clicking on any E-code. (Choose the one relevant to the drug’s use – Accident, Therapeutic, Suicide, Assault or Undetermined). On the tabular, you can review the code and any instructional notes, and manually add the code to the code list.

Using the Tabulars

Searching for Codes in the Tabulars The tabulars enable you to search for a specific code, from either the ICD-9 or CPT Tabulars.

1. In the Search text box, type the code you want to find.

2. Press ENTER or click Go. The body of the tabular scrolls to show the entry, and the entry is selected. The Context Area appears with the entry and its hierarchical place in the tabular. If the code is not in the tabular, the words No results found appear under the Search text box.

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Searching for out of sequence Codes in the Tabulars Out of sequence codes are the codes which are not placed in the correct order of hierarchy. In order to look for the out of sequence code, expand all codes in the CPT Tabular.

Figure 195: Out of Sequence Codes

Table 70: List of out of sequence codes

CODE TYPE

11044 Parent

11045 Out of Sequence Code

11046 Out of Sequence Code

11047 Child Code

27328 Parent

27329 Out of Sequence Code

27339 Child Code

31622 Parent

31623 - 31649 Child Codes

31651 Out of Sequence Code

31652 - 31654 Child Codes

43200 Parent

43201- 43206 Child Codes

43210 Out of Sequence Code

43211 Out of Sequence Code

43212 Out of Sequence Code

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CODE TYPE

43213 Out of Sequence Code

43214 Out of Sequence Code

43215- 43232 Child Codes

43260 Parent

43261- 43265 Child Codes

43266 Out of Sequence Code

43270 Out of Sequence Code

43274 - 43278 Child Codes

44380 Parent

44381 Out of Sequence Code

44382 - 44384 Child Codes

44388 Parent

44389-44394 Child Codes

44401 Out of Sequence Code

44402- 44408 Child Codes

45330 Parent

45331-45342 Child codes

45346 Out of Sequence

45347-45350 Child codes

45378 Parent

45379 - 45386 Child Codes

45388 Out of Sequence Code

45389 Child Code

45390 Out of Sequence Code

45391-45398 Child Codes

64630 Parent

64632 Child Code

64633 Out of Sequence Code

64634 Out of Sequence Code

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CODE TYPE

64635 Out of Sequence Code

64636 Out of Sequence Code

64640 Child Code

87470 Parent

87471-87592 Child Codes

87623 Out of Sequence Code

87624 Out of Sequence Code

87625 Out of Sequence Code

87631-87661 Child Code

87802 Parent

87803 Child Code

87804 Child Code

87805 Child Code

87806 Out of Sequence

87807-87899 Child Codes

Acting on Entries You Find in the Tabulars Each term, or code, in the tabular (and index) has a right-click menu. Point your cursor at the term or code, right-click and the menu opens. See Using Context Menu in the Codes Panel for more details. Other actions you can perform are provided in this section:

How to ...

 Add a Code or Code Modifier to the Codelist (see page 243)

 View More Information for a Code (see page 244)

 View the Tabular Details for an ICD-9 Code (see page 244)

Add a Code or Code Modifier to the Codelist From a tabular, you can click code modifier or press ENTER. For more information about adding codes to the Codelist, see page 291.

Codes must be in a fully expanded list before they can be added to the Codelist.

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CPT code modifiers appear alongside the last CPT code in the Codelist. You can add up to two code modifiers to a CPT code. See Code Modifiers on page 289.

NOTE: You must be working in an encounter to access the CPT code book information.

View More Information for a Code

1. In a tabular, select a term by clicking it.

2. Right-click the text. The context menu appears.

3. Click the link for the kind of information you want.

 You can choose from any of the reference books included with Clintegrity.

 If a link is not available, there are no reference book entries for the term you selected.

View the Tabular Details for an ICD-9 Code

1. In a tabular, select a code by clicking it.

2. If it is available, click the Show Tabular Details link on the upper right corner of the tabular. This opens the Tabular Details screen.

3. Right-click the Notices in the Tabular Details window to access the context menu.

4. Click Close to close the dialog box. For more information about Tab Notations, see Tabular Details on page 217.

Working in Code Books While working in the indexes and tabulars, you find these helpful features:

 Linked Codes (see page 244)

 Crosswalk (see page 245)

 Code Connection (see page 249)

 General Equivalency Mappings (GEM) (see page 252)

 Appendixes (see page 255)

Linked Codes In the ICD-9 Index, some conditions require two separate codes to record both the etiology and manifestation of a disease. Such conditions appear with two codes after the term; the first term represents the etiology; the second term (in brackets) represents the manifestation.

Such terms appear in the ICD-9 Index the same way, but with a distinct advantage – the two codes are linked. Linking means that if you add the first code to your Codelist, the tabular immediately links to the second code so you can easily add it, too.

244 Chapter 7 Using the Code Books

Another type of linked code appears in the books indicated by a :

Figure 196: Code Books: Linked Codes

NUANCE added these entries to help you code. These linked entries work as do the manifestation entries - add the first code to the Codelist and you are immediately transported in the Tabular to the second.

Linked Codes also appear in the ICD-9 Tabular. The Tabular Details note if a particular code in the tabular requires additional codes. See Tabular Details on page 217 for more information.

Crosswalk Crosswalk is a mapping tool between ICD-9 or ICD-10 procedure codes and associated CPT codes. Using crosswalk you can view similar codes from one coding system to another simultaneously and add them to the encounter.

Anesthesia Crosswalk: Anesthesia Crosswalk is a mapping between surgical CPT codes and anesthesia CPT codes. Using anesthesia crosswalk you can view surgical and anesthesia CPT codes simultaneously and add them to the encounter.

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You can Crosswalk from most places you see a procedure code, including:

 ICD-9 Px Index

 ICD-9 Px Tabular

 ICD-9 Px Codelist

 CPT Index

 CPT Tabular

 CPT Codelist

 ICD-10 PCS to CPT

 CPT to PX and ICD-10 PCS

Crosswalk is easy to use, simply find a code in one system and click the Crosswalk icon on the Codes panel. You are given a list of mapping codes in the pop-up window. Crosswalk finds several codes that are possible matches. You choose which one is most appropriate for the patient encounter.

ICD-10 Crosswalk The ICD-10 crosswalk provides an ICD-10 mapping to CPT; PCS to CPT and CPT to PCS and  PX (split pop-up). Any of the linked codes displayed in the pop-up window can be added to the encounter.

Crosswalk Pop-up The crosswalk pop-up for PCS to CPT allows you to view the PCS to CPT codes. This crosswalk pop-up displays related CPT codes and the column label Crosswalk PCS to CPT is displayed in the pop-up window.

Figure 197: Crosswalk Pop-up Window

246 Chapter 7 Using the Code Books

The crosswalk pop-up for CPT to PCS allows you to view the CPT to PCS codes. This crosswalk pop-up displays related PCS codes and the column label Crosswalk CPT to PCS is displayed in the pop-up window.

Figure 198: CPT to PCS Crosswalk Window

The crosswalk pop-up for CPT to PX and CPT to PCS (split pop-up) allows you to view the CPT to PX and CPT to PCS codes. This crosswalk pop-up displays related PCS, CPT, and PX codes and in the split pop-up window, the column labels Crosswalk CPT to PCS and Crosswalk CPT to PX are displayed.

Figure 199: CPT to Px and CPT to PCS Crosswalk Window

NOTE:  CPT to PCS is displayed when you have only the ICD-10 license.  Split pop-up is displayed when you have both ICD-9 and ICD-10 licenses.

Using Crosswalk This procedure applies to procedure codes.

1. Go to the Coding screen. Enter an ICD-9 or ICD-10 procedure code in the Codes panel.

2. Right-click on the code to view the context menu.

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The Crosswalk option is displayed.

Figure 200: Codes Panel Context Menu

3. Click the Crosswalk option. The Crosswalk pop-up window displays.

Figure 201: Crosswalk Pop-up Window

4. On the pop-up window, you can either:

 Click the code to add the code to the codelist.

 Click the Open Code icon to go to the code in the tabular. ( )

5. Click Close to close the Crosswalk dialog box.

For more information, see Crosswalk on page 245.

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Code Connection Code Connection prompts you to select additional ICD-9 and ICD-10 diagnosis, ICD-9 and ICD-10 procedure, CPT, and HCPCS codes that may be relevant to or commonly assigned with another code that was selected.

There are twelve varieties of Code Connections:

 Diagnosis to Term

 Procedure to Term

 Diagnosis to Diagnosis Codes

 Diagnosis to Procedure Codes

 Procedure to Diagnosis Codes

 Procedure to Procedure Codes

 CPT Add-On Codes

 CPT to CPT Codes

 CPT to HCPCS Codes

 HCPCS Add-On Codes

 HCPCS to CPT codes

 HCPCS to HCPCS Codes

The varieties are assembled into three general types of Code Connections:

 Index Term – When it is necessary to report two or more diagnoses or procedure codes, a code connection provides a listing of index terms to choose to help complete the coding through the respective index search. Once you select a term from the list, the cursor moves to the book Search Terms field so that a search for the selected term in the Index can be performed to link to the Tabular List for code selection.

Figure 202: Code Connection - Index Term

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 Code – When it is necessary to report two or more diagnoses or procedure codes, a code connection provides a listing of related codes to select to quickly complete the coding. Once you select code(s) from the list, click Add Codes to populate to the codelist. Depending on the code, more than one variety of Code Connection may be available for that code.

Figure 203: Code Connection - Diagnosis to Procedure

 Add-on Codes (CPT and HCPCS) – When it is necessary to report add-on codes, a code connection provides a listing of additional procedures or services to select from that may be performed in conjunction with another primary procedure or service to quickly complete coding. Once you select code(s) from the list, click Add Codes to populate to the codelist.

Figure 204: Code Connection - Add-on Codes

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Using Code Connection If you do not want to select any of the Code Connection choices, you can exit Code Connection:

1. Click the Code Connections icon in the Codes panel. ( ) The Code Connection dialog box pops up.

Figure 205: Code Connections Pop-up Window

2. Click the checkbox next to the code and click Add Codes to the codelist. The code(s) are added to the codelist.

There are 12 different Code Connection pop-up windows:

Table 71: Code Connection Types and Actions

TYPE DESCRIPTION ACTIONS

Diagnosis Lists codes that are commonly assigned Select codes to add to codelist or view together or as coding instructions advise. code information by clicking

Procedure Lists codes that are commonly assigned Select codes to add to codelist or view together or as coding instructions advise. code information by clicking

Add-On Codes/Code to Lists CPT codes that are commonly used Select codes to add to codelist or view Code Connection with a code. code information by clicking

To add codes, check the checkbox next to the code and click Add Codes to the codelist. This action also closes the pop-up window and returns you to the Coding screen.

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General Equivalency Mappings (GEM) The GEM pop-up window displays the corresponding ICD-10 codes for the entered ICD-9 Dx or Px codes.

1. Go to Coding screen. Enter an ICD-9 code in the Codes panel.

2. Right-click on the code to view the context menu. MSThe GE option is displayed.

GEMS option

Figure 206: Codes Panel - GEMS Context Menu

3. Click the GEMS option. MS The GE pop-up window appears.

Figure 207: GEM Pop-up Window

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The GEM pop-up window displays the following information:

 ICD-10 Code

 ICD-10 Description

 ICD-9 Code

 ICD-9 Description

 Approximate Flag  0 – Identical Match  1 – Approximate Match

 No Map Flag  0 – At least one plausible translation  1 – No plausible translation

 Combination Flag  0 – Code maps to a single code  1 – Code maps to more than one code

 Scenario Flag – In a combination entry, a collection of codes from the target system containing the necessary codes that combined as directed satisfies the equivalent meaning of a code in the source system.

 Choice List Flag – In a combination entry, it displays number of choices for one or more codes in the target system from which one code must be chosen to satisfy the equivalent meaning of a code in the source system.

NOTE: Descriptions may be wrapped to additional lines, if necessary. If data for any of the flags does not exist, the flag value appears as blank.

The GEM pop-up window displays all ICD-9 codes associated with the selected ICD-10 code.

NOTE: A maximum of 10 ICD-9 codes can be displayed, in a numeric order, on the pop-up screen. If more than 10 codes are encountered, the system displays the additional codes on the next page.

The system displays the total number of the GEM found in the following format: Total GEM Found: The GEM pop-up window view does not allow vertical or horizontal scrolling.

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Searchable GEM Reference Screen A searchable reference screen is displayed for GEM mapping between ICD-9 and ICD-10 codes. This screen allows the mapping of ICD-9 codes to ICD-10 and vice versa via the References list. The GEM Reference link is one of the available reference selections.

Alternatively, the G GEM Reference link can also be accessed from the References menu bar in Coding/ Abstracting\References.

Figure 208: GEM Reference Screen

QLines QLines are Index lines that are added by NUANCE to enhance the index search. The QLine symbol is displayed on the left side of the QLine to visually indicate that it is value added content. All searches performed will automatically also include QLines.

Example seen in the ICD-10-CM Alphabetic Index:

Figure 209: QLines Section

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Synonyms Synonyms (medical abbreviations and acronyms) are added to the standard index search programming by NUANCE to assist the coder when performing a code search by reducing keystrokes. See View Synonyms on page 75 for more information.

See Synonyms section on Synonyms on page 439 for more information on Synonyms list.

Smartips Smartips provide additional comments or information that can apply to a code or range of codes and assist coders while performing the coding process to assign codes with greater accuracy based on advice from selected professional, official, and regulatory sources. Not all codes will have a Smartip. Smartip pop-up displays only when a Smartip exists for the code and has been selected to do so in Set-Up. See View Smartips on page 79 for more information.

Appendixes Access the related ICD-9-CM and CPT appendixes when in the Dx, Px, E-Code, or CPT code books. The tab for the appendixes that are included in the official version of the code books is located in the upper left-hand corner of the Code Books window. Click the View Appendix tab to see the appendixes for the code book you are looking at.

View Appendix tab

Figure 210: Code Books Window - Appendix Tab

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Using Context Menu in the Codes Panel Context menu is powerful tool you can access by right-clicking on a code row in the Codes panel.

Right-click on codes in the Codes panel to access the context menu.

Figure 211: Code Grid Context Menu Options in CM

The context menu displays only relevant options for the code you have right-clicked on (irrelevant options are hidden). All menu options are explained here:

Table 72: Context Menu Options and Actions in Code Grid

OPTION ACTION SEE

Move to principal Move selected code to principal diagnosis (Dx and/or page 298 Diagnosis CM codes)

Move to Principal Move selected code to principal procedure (CPT and/ page 298 Procedure or HCPCS codes)

Copy to Admitting Copy the code as the Admitting Diagnosis (Dx and/or page 298 Diagnosis CM) code on the encounter.

Copy to Reason for Visit Copy the code as the Reason for Visit (Dx and/or CM) page 299 code on the encounter.

Copy Previous Episode Copy the previous episode information to the page 303 Information procedure code

Add Charge Modifiers Add charge modifiers from Affinity. N/A NOTE: This option is available only when you have the Affinity license.

Insert Row Right-click on the codelist to insert a blank row. N/A

Edit Episode Info Add or edit the Episode Number, Date, Time and Provider for respective PCS code.

Verify Right-click on the codelist to verify the selected code. N/A

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OPTION ACTION SEE

Delete Row Right-click on the codelist to delete the selected row. page 300

Smartips View Smartips for code. page 255

Coding Clinic View related entries in the Coding Clinic reference. page 271

Coding Clinic for HCPCS View related entries in the Coding Clinic for HCPCS page 277 reference.

ICD-10 Coding Clinic View related entries in the ICD-10 Coding Clinic page 264 reference.

Medical Necessity View policy for the HCPCS code only for outpatient N/A encounters.

CPT Assistant View related entries in the CPT Assistant reference. page 273

ICD-9 Guidelines View ICD-9 Coding Guidelines for the code page 274

ICD-10 CM Guidelines View ICD-10 CM Coding Guidelines for the code. page 263

ICD-10 PCS Guidelines View ICD-10 PCS Guidelines for the code. page 269

Clinical Indicator View related entries in the Clinical Indicator reference. page 270

GEMS View related entries in the GEMS reference. page 252

Crosswalk Start Code Crosswalk. page 245

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Using Context Menu in Codebooks You can access context menu by right-clicking on a code hyperlink in Codebooks.

Right-click on codes in the Standalone Code Books to access the context menu.

Figure 212: Codebook Context Menu Options The context menu displays only relevant options for the code you have right-clicked on (irrelevant options are hidden). All menu options are explained here:

Table 73: Context Menu Options and Actions in Codebook

OPTION ACTION SEE

Anatomy View related entries in the Anatomy reference page 262

Coding Guidelines View related entries in the Coding Guidelines reference page 274

Lab Values View related entries in the Lab Values reference page 275

Drugs View related entries in the Drugs reference page 276

Medical Dictionary View related entries in the Medical Dictionary reference page 277

Add to Admitting Diagnosis Adds code as the Admitting Diagnosis code page 292

Add to Principal Procedure Adds code as the principal procedure code from the N/A codebooks

Add to Reason for Visit Adds code as the Reason for Visit code page 299

NOTE: The References pop-up window displays when you select a reference context-menu (Anatomy, Coding Guidelines, Lab Values, Drugs, or Medical Dictionary) for a code under Code Books. You can return to Code Books after closing the References pop-up window.

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Chapter 8 Reference Books

The reference books provided in Coding/Abstracting give you guidelines for coding, although they do not contain specific code. This section discusses:

 Navigating Through Reference Books (see page 259)

 Searching Within the Reference Books (see page 260)

Navigating Through Reference Books

How to ...

Select a Specific Reference There are several ways you can select the Reference you want to access

 Select an encounter and click the Stand-alone icon to view the References pop-up window.

 Use the secondary navigation drop down list next to the References tab.

Figure 213: View Encounters: Default View Screen

 While working within the References themselves, use the list of books at the far left of the page. Click any title to access that reference.

 Collapse this list, by clicking the minus sign at its top right, anytime you want more room on the page for the reference book in which you are working.

 If collapsed, the minus sign becomes a plus sign. Click the plus sign to open the list.

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Understand Reference Book Display In each of these reference books, the information is presented in similarly to the information shown below:

Select the name of the reference book you want to access. Enter your search criteria, then click the Search icon.

The left pane appears with a list of terms that Information on the item you selected in the left pane match your search criteria. Click the item you appears in the right pane. If headers display (as here), want to review. click any for specific information about the item.

Figure 214: References Screen

NOTE: The ICD-10 PCS Reference Manual, ICD-10 PCS Guidelines, and ICD-10 CM Guidelines References can be used for both the OP and the IP encounters.

Searching Within the Reference Books

How to ...

 Search Anatomy Reference (see page 262), for graphical information on various body systems.

 Search ICD-10 CM Guidelines Reference (see page 263), for the ICD-10-CM Official Guidelines for Coding and Reporting.

 Search ICD-10 Coding Clinic Reference (see page 264), for a full-text version of the ICD-10 coding guidelines.

 Search ICD-10 PCS Reference (see page 267), for the ICD-10 Official PCS References for Coding and Reporting.

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 Search ICD-10 PCS Reference Manual Reference (see page 268), for the ICD-10 Official PCS References for Coding and Reporting.

 Search ICD-10 PCS Guidelines Reference (see page 269), for the ICD-10-PCS Official Guidelines for Coding and Reporting.

 Search Clinical Indicators Reference (see page 270), for comprehensive information about ICD- 9 and ICD-10 codes you can use to better understand procedures or disease processes.

 Search Coding Clinic Reference (see page 271), for a full-text version of the coding guidelines and advice published by the American Hospital Association.

 Search CPT Assistant Reference (see page 273), for CPT coding information published by the American Medical Association.

 Search ICD-9 Guidelines (see page 274) for the ICD-9- Official Guidelines for Coding and Reporting.

 Search Drug Reference (see page 276), for a full-text version of the Thomson Micromedex Drug Database.

 Search Lab Values Reference (see page 275), for explanations and implications of laboratory test values.

 Search Medical Dictionary Reference (see page 277), for complete definitions and exact spellings of medical terms.

 Search Coding Clinic for HCPCS (see page 277), for a full-text version of the coding guidelines and advice specific to HCPCS.

 Search Abbreviations, Acronyms and Symbols (see page 278), for Stedman’s Abbreviations, Acronyms and Symbols.

 Search GEM Reference (see page 279), for:

 ICD-9 Diagnosis to ICD-10 Diagnosis

 ICD-9 Procedures to ICD-10 PCS

 ICD-10 Diagnosis to ICD-9 Diagnosis

 ICD-10 PCS to ICD-9 Procedures

 Search Faye Brown (see page 280), for the Faye Brown Coding Handbook (available to facilities that have purchased a separate specific license for it)

 Search ICD-10 Handbook (see page 281), for the ICD-10 Handbook.

 Search Coder’s Desk References (see page 283), for the Coder’s Desk Reference (available to facilities that have purchased a separate specific license for it).

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Search Anatomy Reference The A.D.A.M. Anatomy reference software is a third-party software used within Clintegrity. The Anatomy reference can also be accessed from the context menu while coding by right-clicking a selected term or code.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Anatomy from the Search drop-down.

Figure 215: Anatomy Reference Screen

3. Select CM/CPT/DX from the drop-down list.

4. Enter a term or code on which to search in the Search field and Press ENTER or click the Search icon. ( )

The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

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Search ICD-10 CM Guidelines Reference Use ICD-10 CM Guidelines to review information to guide coding provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS). These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-10 CM Guidelines from the Search drop-down.

NOTE: The ICD-10 CM Coding Guidelines reference can also be accessed from the context menu while coding by right-clicking a selected term or code.

Figure 216: ICD-10 CM Guidelines Reference Screen 3. From Bookmarks select the Section/Chapter to be directed to that content..

NOTE: Sections/Chapters do not need to be selected to perform searches. By selecting specific Sections/Chapters searches will start within that specific Section/Chapter and will include the entire reference.

4. To Search:

a. Select Search icon ( ), enter codes or terms within the Search bar  Press ENTER or click on the Search button b. Perform CNTL + F: enter codes or terms within Find bar  Press Enter and/or click on Next or Previous button

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Search ICD-10 Coding Clinic Reference ICD-10 Coding Clinic is the full text of AHA Coding Clinic for ICD-10, the quarterly publication by the American Hospital Association Central Office on ICD-10. This publication includes official guidelines for accurate and complete coding. When more than one Coding Clinic article is associated with a code, articles appear in reverse chronological order, with the most recent article appearing first. Each Coding Clinic article is marked with the volume number and date of its publication. NOTE: ICD-10 Coding Clinic feature supports 7-character partial CM codes. 1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-10 Coding Clinic from the Search drop-down. The ICD-10 Coding Clinic reference can also be accessed from the context menu while coding by right-clicking a selected term or code and choosing the ICD-10 Coding Clinic link.

Figure 217: ICD-10 Coding Clinic Reference Screen

3. Select the code type from the Search drop-down list.

4. Enter the search term or code in the Search field. You can search on:

 Codes – Single code, minimum of three characters

 Terms – Single or multiple terms, minimum of three characters

5. Choose Index Term or Full Term from drop-down relevant to your search:

 Index Term – Searches index entries for any of the words entered. This is the default search type.

 Full Term – Searches for articles containing any of the words entered.

6. Press ENTER or click the Search icon. ( ) Matching articles in the Terms Matched list are displayed.

7. Select a matching term from the Terms Matched list. Matching articles for the selected term are displayed.

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8. Select the article to view. The article displays in a new PDF window with a list of matching articles to the left side of the window. You can navigate between articles by selecting a link from the left side tree.

Figure 218: Coding Clinic for ICD-10 CM Article

9. You can view all available issues of the Coding Clinic by clicking the View All Issues link.

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10. Select an issue to view. The issue opens in a new PDF window with a list of indexed articles in that issue. A link of the full issue is also displayed at top of articles list.

Figure 219: Coding Clinic for ICD-10 CM Article - Full Issue

NOTE: When you select an article from the list, only that article displays in the reading pane and printing is allowed for that article. To view the full issue in the reading pane, select the issue link at top of the list.

You can view the latest issue of ICD-10 Coding Clinic by clicking the Latest Issue link.

NOTE: When you select to view a full issue or latest issue, the Print button is disabled in the PDF window.

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Search ICD-10 PCS Reference Use ICD-10 PCS Reference to review information to guide coding that was developed with the support of the Centers for Medicare and Medicaid Services (CMS) under contract with 3M™ Health Information Systems.

The ICD-10-PCS Reference provides reference material on PCS code structure, root operation definitions, code examples, and coding exercises. It contains listings of the root operations by section, approaches with definitions and device and substance classification references.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-10 PCS Reference from the Search drop-down.

NOTE: The ICD-10 PCS Reference reference can also be accessed from the context menu while coding by right-clicking a selected term or code.

3. Enter the information on which to search in the Search Terms field. You can search on:

 Codes – Single code.

 Terms – Single term, minimum of three characters.

4. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane.

5. Click the desired term to display the content in the right-hand pane.

6. Click the View All Chapters link if you want to view the list of all available chapters of the ICD-10 PCS Reference.

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Search ICD-10 PCS Reference Manual Reference Use ICD-10 PCS Reference Manual to review information to guide coding that was developed with the support of the Centers for Medicare and Medicaid Services (CMS) under contract with 3M™ Health Information Systems.

The ICD-10-PCS Reference Manual provides reference material on PCS code structure, root operation definitions, code examples, and coding exercises. It contains listings of the root operations by section, approaches with definitions and device and substance classification references.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-10 PCS Reference Manual from the Search drop-down.

NOTE: The ICD-10 PCS Reference Manual reference can also be accessed from the context menu while coding by right- clicking a selected term or code.

3. Enter the information on which to search in the Search Terms field. You can search on:

 Codes – Single code.

 Terms – Single term, minimum of three characters.

4. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane.

5. Click the desired term to display the content in the right-hand pane.

6. Click the View All Chapters link if you want to view the list of all available chapters of the ICD-10 PCS Reference Manual.

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Search ICD-10 PCS Guidelines Reference

Use ICD-10 PCS Guidelines to review information to guide coding that was developed with the support of the Centers for Medicare and Medicaid Services (CMS) under contract with 3M™ Health Information Systems. These guidelines are based on the coding and sequencing instructions in the Tables, Index and Definitions of ICD-10-PCS and provide additional instruction.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-10 PCS Reference from the Search drop-down.

NOTE: The ICD-10 PCS Reference reference can also be accessed from the context menu while coding by right-clicking a selected term or code.

Figure 220: ICD-10 PCS Guidelines Reference Screen 3. From Bookmarks select the Section/Chapter to be directed to that content. NOTE: Sections/Chapters do not need to be selected to perform searches. By selecting specific Sections/Chapters searches will start within that specific Section/Chapter and will include the entire reference. 4. To search:

a. Select Search icon ( ), enter codes or terms within the Search bar  Press ENTER or click on the Search button b. Perform CNTL + F: enter codes or terms within Find bar  Press Enter and/or click on Next or Previous button

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Search Clinical Indicators Reference Clinical Indicators provide comprehensive information about ICD-9 and ICD-10 diagnoses and procedures. They are compiled by HIM Professionals from a variety of medical resources and references.

Clinical Indicators are intended to enhance the coder’s knowledge of the cause, manifestations, and treatment of disease processes. They are not intended to be a guide to clinical management or a tool for case management review.

For each Dx or CM code listed, there is a description of disease processes and information about the symptoms, standard treatment practices, and documentation guidelines.

For each Px or PCS code listed there is a description of the process, sample conditions on which the procedure is performed, and a description of the procedure.

The Clinical Indicators reference can also be accessed:

 From the context menu while coding by right-clicking a selected code and choosing the Clinical Indicators reference.

 By clicking the Clinical Indicators link adjacent to the code. NOTE: The Clinical Indicators icon is also available on ICD-10 CM Diagnosis tabular list, for 7-character partial CM codes.

To use the Clinical Indicators reference:

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Clinical Indicators from the Search drop-down.

3. Enter a term or code on which to search in the Search field. Press ENTER or click the Search icon. ( )

Figure 221: Clinical Indicators Reference Screen

4. Review the results displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

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5. If the entry in the right-hand pane is very long, click the links at the top of the pane to bring the specific sub-set of information to the top of the pane.

Search Coding Clinic Reference Coding Clinic is the full text of AHA Coding Clinic for ICD-9, the quarterly publication by the American Hospital Association Central Office on ICD-9. This publication includes official guidelines for accurate and complete coding. When more than one Coding Clinic article is associated with a code, articles appear in reverse chronological order, with the most recent article appearing first. Each Coding Clinic article is marked with the volume number and date of its publication.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Coding Clinic from the Search drop-down. The Coding Clinic reference can also be accessed from the context menu while coding by  right-clicking a selected term or code and choosing the Coding Clinic link. Additionally, you can click the Coding Clinic link adjacent to the code.

Figure 222: Coding Clinic Reference Screen

3. Select the code type from the Search drop-down list.

4. Enter the search term or code in the Search field. You can search on:

 Codes – Single code, minimum of three characters

 Terms – Single or multiple terms, minimum of three characters

5. Choose Index Term or Full Term from drop-down relevant to your search:

 Index Term – Searches index entries for any of the words entered. This is the default search type.

 Full Text – Searches for articles containing any of the words entered.

6. Press ENTER or click the Search icon. ( ) Matching articles in the Terms Matched list are displayed.

7. Select a matching term from the Terms Matched list. Matching articles for the selected term are displayed.

8. Select the article to view.

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The article displays in a new PDF window with a list of matching articles to the left side of the window. You can navigate between articles by selecting a link from the left side tree.

Figure 223: AHA Coding Clinic Article

NOTE: When you select an article from the list, only that article displays in the reading pane and printing is allowed for that article. To view the full issue in the reading pane, select the issue link at top of the list.

9. You can view all available issues of the Coding Clinic by clicking the View All Issues link.

10. Select an issue to view. The issue opens in a new PDF window with a list of indexed articles in that issue. A link of the full issue is also displayed at top of articles list.

Figure 224: AHA Coding Clinic Article - Full Issue

11. You can view the latest issue of Coding Clinic by clicking the Latest Issue link.

NOTE: When you select to view a full issue or latest issue, the Print button is disabled in the PDF window.

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Search CPT Assistant Reference Use CPT Assistant to review information from the AMA’s coding guidance. This publication includes guidelines, updates and AMA coding advice related to specific questions and coding scenarios.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select CPT Assistant from the Search drop-down. (The CPT Assistant reference can be accessed from the context menu while coding by right- clicking a selected term or code and choosing the CPT Assistant link from the list).

Figure 225: CPT Assistant Reference Screen

2. Select a code type from the search type drop-down list.

3. Enter the information on which to search in the Search Terms field. You can search on:

 Codes – Single code, CPT, DX, CM, or PCS only, minimum of five characters

 Terms – Single or multiple terms, minimum of three characters

NOTE: CPT is the default search term.

4. Choose Index Term or Full Term from drop-down relevant to your search:

 Index Term – Searches index entries for any of the words entered. This is the default search type.

 Full Text – Searches for articles containing any of the words entered.

5. Press ENTER or click the Search icon. ( )

 The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

 You can read only the article related to your search. You cannot scroll within the issue to read other articles. For example, if you search for Glaucoma, you can read in the August 2003 issue an article on Glaucoma Drainage Devices. There are several other articles in the August 2003 issue, including one on trigger point injections. You need to search on Trigger Point Injections to access that article. You cannot scroll to it from the glaucoma article.

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Search ICD-9 Guidelines Use ICD-9 Guidelines to review information to guide coding provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS). These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select ICD-9 Guidelines from the Search drop-down. (The ICD-9 Guideline reference can also be accessed from the context menu while coding by right-clicking a selected term or code.)

Figure 226: ICD-9 Guidelines Reference Screen

3. Select Px or Dx from the drop-down list to indicate what kind of code to search on

4. Enter the information on which to search in the Search Terms field. You can search on:

 Codes – Single code.

 Terms – Single or multiple terms, minimum of three characters.

5. Choose Index Term or Full Term from drop-down relevant to your search:

 Index Term – Searches index entries for any of the words entered. This is the default search type.

 Full Text – Searches for articles containing any of the words entered.

6. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

7. Click the View All Issues link if you want to view list of all available issues of the ICD-9 Guidelines.

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Search Lab Values Reference Use the Lab Values reference to obtain information about laboratory tests. With this information, you can query a physician or search a record to obtain the documentation required for accurate coding. The Lab Values reference information box contains:

 Test’s full name  Purpose of the test

 Common synonym  Implications of results

 The terms associated with the test  Coder alert

 Definition of the test

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Lab Values from the Search drop-down. (The Lab Values reference can also be accessed from the context menu while coding by right- clicking a selected term.)

Figure 227: Lab Values Reference Screen

3. Enter a term on which to search in the Search field. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

4. If the entry in the right-hand pane is very long, click the Description, Purpose, Result Implication or Coder Alert links at the top of the pane to bring the specific sub-set of information to the top of the pane.

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Search Drug Reference The full-text version of the Thomson Micromedics Drug Guide is an online database of information on drug names and the conditions for which they are prescribed. It helps you find additional information on drugs or conditions that might not be clearly documented.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Drugs from the Search drop-down.

Figure 228: Drugs Reference Screen

3. Enter a term on which to search in the Search field. Press ENTER or click the Search icon. ( )

4. The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane. Click the desired term to display the content in the right-hand pane.

5. If the entry in the right-hand pane is very long, click the links at the top of the pane to bring the specific sub-set of information to the top of the pane.

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Search Medical Dictionary Reference The reference contains a special online edition of Stedman’s Medical Definitions. This book can facilitate coding precision by helping you understand the exact meaning, and thus the coding implications, of a medical term. In addition to the definition for every term, many terms also contain common synonyms, etymology, subterms, and synonyms.

The Medical Dictionary reference can also be accessed from the context menu while coding by right- clicking a selected term.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Medical Dictionary from the Search drop-down.

Figure 229: Medical Dictionary Reference Screen

3. Enter a term on which to search in the Search field. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane.

4. Click the desired term to display the content in the right-hand pane.

Search Coding Clinic for HCPCS

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Coding Clinic for HCPCS from the Search drop-down.

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The Coding Clinic for HCPCS can also be accessed from the context menu while coding by right-clicking a selected term or code and choosing the Coding Clinic for HCPCS link. Additionally, you can click the Coding Clinic-HCPCS link adjacent to the code.

Figure 230: Coding Clinic for HCPCS Reference Screen

3. Enter your search terms in the Search field.

4. Choose Index Term or Full Term from drop-down relevant to your search:

 Index Term – Searches entries for any of the words entered. This is the default search type.

 Full Text – Searches for articles containing any of the words entered.

5. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list of indexed titles is displayed in the left-hand pane.

6. Click the desired term to display the content in the right-hand pane. The relevant article is displayed in blue text.

Search Abbreviations, Acronyms and Symbols

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Abbreviations from the Search drop-down.

Figure 231: Abbreviations Reference Screen

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3. Enter the abbreviation or acronym in the Search field.

4. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list of indexed titles is displayed in the left-hand pane.

5. Click the desired term to display the content in the right-hand pane.

Search GEM Reference If you have purchased the additional license for the GEM Reference, you can access it.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select GEM Reference from the Search drop-down.

3. In the Search Terms field, select a code type from the drop-down menu and type the search text in the Search text box. The following options are available in the drop-down:

 9-DX -> 10-CM

 9-PX -> 10-PCS

 10-CM -> 9-DX

 10-PCS -> 9-PX

NOTE: The Search text box accepts only the ICD codes for the search values.

4. Press ENTER or click the Search icon. The search results are displayed in the Search Results area. A code and its corresponding description are displayed for each result.

Figure 232: GEM Reference Screen

5. Select an item from the Search Results area. The GEM matching code(s) are displayed in the Matching Reference Code area. The Matching Reference Code area displays the code and a description for each matching reference.

NOTE: The long description is used when displaying the ICD-9 results.

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Search Faye Brown If you have purchased the additional license for the Faye Brown reference, you can access it.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Faye Brown from the Search drop-down.

Figure 233: Faye Brown Reference Screen

3. Enter the information on which to search in the Search field. You can search on for codes and terms.

 If searching for a diagnosis or procedure code, enter at least 5 characters.

 If searching for single or multiple terms, enter at least 3 characters.

4. Select the Full Text search type to search terms and codes.

5. Press ENTER or click the Search icon. ( )

6. Review the results displayed in the lower panes of the page. If there are multiple results, a hyperlinked list is displayed in the left-hand pane.

7. Click the desired term to display the content in the right-hand pane.

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Search ICD-10 Handbook

If you have purchased the additional license for the ICD-10 Handbook reference, you can access it. NOTE: This reference must be purchased separately, but if you had the Faye Brown license, then the ICD-10 Handbook will be provided to you as a replacement for that reference. 1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select the ICD-10 Handbook from the Search drop-down. List of all the chapters is displayed in the Content section.

Figure 234: ICD-10 Handbook Reference Screen

3. Enter the search term/s in the Search field and click the search icon. NOTE: Multiple search terms can be searched by separating them by ','. Results for all the search terms can be shown together.

 The table of contents for chapters are filtered and those chapters containing the search term are displayed.

 Chapter/Article results display within the left window panes.

 If you click on the Chapter, only the articles containing the search term in their text would be listed.

 After search results are filtered for any search term, select View All Chapters, to display all Chapters. See step 8.

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NOTE:

 The chapter overview of the chapter will be displayed in the right window pane by default, irrespective of the search term being present in overview.

 To aid in identifying search terms within the content on the right-hand side of the pane, perform a left mouse click. Press CTRL + F and type in the term/s to be identified.

Figure 235: Filtered Table of Contents

4. Once you click any of the articles listed in the article pane, you can see its text in right pane, which contains search term.

Figure 236: Article Text

5. If the search terms is entered in the Search field and the Enter button is pressed, similar results are displayed as shown above in Step 3.

6. Select a different reference option from the Search drop-down.

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Type in the search term in the Search field and without clicking the search icon, switch to the ICD10-Handbook reference. The search result will be shown as below:

7. Type in multiple search terms by using comma (,) as a separator.

8. After search results are filtered for any search term, click on View All Chapters link, all the chapters would be listed.

Search Coder’s Desk References If you have purchased the additional license for the CDR, you can access it.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select CDR from the Search drop-down.

Figure 237: Coder’s Desk Reference Screen

3. Enter the information on which to search in the Search Terms field.

4. Choose Full Term or Code Term from drop-down relevant to your search:

 Full Term – To search for a term. The term can be a single word (heart), multiple words (heart disease), or the first three letters of a word (hea).

 Code Term – To search for the code or part of a code.

5. Press ENTER or click the Search icon. ( ) The results are displayed in the lower panes of the page. If there are multiple results, a hyperlinked list of indexed titles is displayed in the left-hand pane.

6. Click the desired term to display the content in the right-hand pane. The relevant article is displayed in blue text.

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Search Interventional Radiology Coding If you have purchased the additional license for the Interventional Radiology Coding reference, you can access it.

1. Select an encounter and click the Stand-alone icon to view the References pop-up window.

2. Select Interventional Radiology from the Search drop-down. NOTE: The Interventional Radiology reference can also be accessed from the context menu while coding by right-clicking a selected term or code. 3. Enter the search term or code in the Search field. You can search on:

 Codes - Single code, minimum of three characters

 Terms - Single term, minimum of three characters.

4. Press ENTER or click Search ( ).

Figure 238: Interventional Radiology- Search Results in Facility Coding The results are displayed in the lower panes of the page. If there are multiple results, a list is displayed in the left-hand pane.

5. Click the desired term to display the content in the right-hand pane.

6. Click the View All Chapters link if you want to view the list of all available chapters of the Interventional Radiology.

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Chapter 9  Codelist

While the code books are where you might spend time researching codes, the Codelist is where you record the results of your research. It is where you post the codes to the patient’s record.

This section provides you information about:

 Overview of the Codelist

 Code Types and Lists

 Adding Codes to the Codelist

 Modifying Codes in the Codelist

 Entering Additional Procedure Information

 Using the Editor

Overview of the Codelist Once you collect codes in the Codelist, the Clinical Data Editor checks your Codelist for correct coding practices and suggests edits you can make to correct any coding discrepancies. When you have addressed all the edits, you can generate a DRG or price an ASC encounter. See Using the Editor on page 303.

The Codelist is actually a collection of several lists of codes:

 Admitting Diagnosis (ADx)

 ICD-9 Principal Diagnosis (PDx)

 ICD-9 Diagnosis (Dx)

 ICD-9 Procedures (Px)

 ICD-10 Diagnosis (CM)

 ICD-10 Procedures (PCS)

 ICD-10 Principal Diagnosis (PCM)

 CPT/HCPCS Procedures (CPT/HCPCS)

Each visit a patient makes to a facility could result in several diagnoses or procedures— think of the Codelist as a worksheet for coding that patient’s record.

Clintegrity 360 | Coding and Clintegrity 360 | Abstracting give you several ways to find appropriate codes and add them to a patient’s Codelist. You can look up codes in the code books and add them to the Codelist in any order. You can change the order of the codes in the list, and even change their descriptions. See Modifying Codes in the Codelist on page 298 for instructions.

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A Codelist Populated with Coding Information For more information, please refer Multi-Panel View (Codebook and Code Grids) section.

Reason for Visit Fields The reason for visit fields only appear for outpatient encounters for facilities where the Display Reason for Visit Facility Preference has been selected.

See Set Up Facility Preferences on page 53 for information on setting up facility preferences.

Reason for visit fields – see (see page 299) to add reasons for visit.

Figure 239: Reason for Visit Fields Window

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Code Types and Lists

 Linked Codes (see page 244)

 Code Packages (see page 289)

 Code Builders (see page 289)

 Code Modifiers (see page 289)

Code Packages Code Packages are simply a way to store a completed Codelist for later use. They are especially useful for patient encounters that run a typical course of diagnoses and procedures.

You can click the Code Packages icon on the code list to access the Code Packages  50/50 split panel. ( )

For example, a cataract extraction might run a common course, so a protocol called Cataract Extraction could be created to store all the codes that apply to a cataract extraction. To code a cataract extraction, you could access the Code Package for Cataract Extraction to quickly fill out the Codelist with the relevant codes. See Add Code Packages to the Codelist on page 293 for more information.

Code Builders In difficult coding situations, you can use the Code Builder to find CPT codes for commonly performed procedures. The Code Builder acts as a wizard, asking questions and then directing you to the proper place in the index or tabular based on your responses. For information about building and adding codes to the Codelist, see Add Codes From the Code Builder on page 295.

You can click the Code Builder icon on the code list to access the Code Builders window. ( )

When you are coding encounters with a patient type of Physician, there is an E & M Code builder available to you. The E & M Code Builder works the same as the Code Builder in Facility coding. It acts as a wizard, asking questions about a patient’s visit and the medical complexity of the visit. It then directs you to the proper place in the index or tabular based on your responses. For information about building and adding codes to the Codelist.

Code Modifiers Modifiers are used in addition to a CPT code to add more information on the billing claim form. These modifiers state special circumstances that affect the amount the provider or facility will be reimbursed. Modifiers are used for evaluation and management as well as procedure codes. Documentation of special circumstances is sometimes required by the payor to receive full reimbursement on the claim, but guidelines vary from payor to payor.

Clintegrity 360 | Coding and Clintegrity 360 | Abstracting support HCPCS Level I and Level II code modifiers for use with CPT codes. All CPT modifiers are listed in the CPT Tabular in the Modifiers section (see Using the Tabulars on page 240).

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In Clintegrity 360 | Coding/Clintegrity 360 | Abstracting, you add CPT modifiers to two special columns in the CPT Codelist.

Code modifiers

Figure 240: Code Modifiers

You add a modifier to the Codelist much in the same way as you do a code. You type the modifier into the Codelist in the Modifier columns.

The Add Charge Modifiers option in the Clintegrity 360 | Coding context menu allows you to directly launch from Clintegrity to the listing of charge codes and applicable CPT/HCPCS codes in Affinity to add modifiers. After adding/editing modifiers to applicable charge based CPT/HCPCS codes, you can return to Clintegrity 360 | Coding for viewing updated information.

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Adding Codes to the Codelist Adding codes to the Codelist is usually a simple matter of selecting a code in a tabular and double-clicking on it. There are, however, other ways to add codes, including typing the code directly into the Codelist. This is called direct code entry, and you might not have the ability to do this on your system. Check with your System Administrator to find out if you do.

Unless noted, all the procedures in this section assume you have already opened the Tabular.

How to ...

 Search for a Code From the Codelist (see page 291)

 Add a Code as an Admitting Diagnosis Code (see page 292)

 Directly Code an Admitting Diagnosis (see page 292)

 Add ICD-9, ICD-10, or CPT/HCPCS Codes to the Codelist (see page 292)

 Add Linked Codes to the Codelist (see page 293)

 Add Linked Codes from the ICD-9 Index (see page 293)

 Add Linked Codes from the ICD-9 Tabular (see page 293)

 Add Code Packages to the Codelist (see page 293)

 Add Codes From the Code Builder (see page 295)

 Type a CPT Code Modifier Directly Into The Codelist (see page 296)

 Add Condition Codes (see page 296)

Search for a Code From the Codelist If you do not know the code—Dx, PX, or other types of code—you can search for it as follows:

1. In the Codelist, put your cursor in an empty code field (not in a description field).

2. Press the SPACEBAR to pop up the search window, or you can type a few characters of the term or code, and then press SPACEBAR.

Figure 241: Search a Code Window

3. Notice that your cursor has moved to the text field in the pop-up window.

If you entered a few characters before pressing the SPACEBAR, those characters appear in the search term field.

4. Type the code or term you are searching for.

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5. Tab to or click the button relevant to which code book you want to search.

Click ENTER if you want to search from where you started -- for example, if you begin the search with your cursor in the Px field, clicking ENTER returns a Px search.

6. When the code you want displays, double-click it or press ENTER to add it to the Codelist.

Add a Code as an Admitting Diagnosis Code You can add an Admitting Diagnosis to an encounter in the following ways:

 The Admitting Diagnosis code can be entered directly in the codelist, as described in Directly Code an Admitting Diagnosis on page 292.

 Any diagnosis code in the codelist can be copied to the admitting diagnosis, or vice versa (see Modifying Codes in the Codelist on page 298).

Directly Code an Admitting Diagnosis If you find that you cannot directly enter a code, you might not have privileges to do so. Check with your System Administrator to see if you do.

In the codelist, click to place the focus in the Admitting Diagnosis (P) or Admitting Diagnosis (S) code entry field, then add the code for the Admitting Diagnosis.

1. Type the code number you want to use—it must be exact and an acceptable code. If you do not enter a decimal point, the system automatically places it where it should go.

 If you do not know the code, you can search for it and then enter it, following the process at Search for a Code From the Codelist on page 291.

2. Press ENTER or TAB. The code description appears.

 If the code field turns yellow, there is an error in the code. The system allows you to save the data.

Add ICD-9, ICD-10, or CPT/HCPCS Codes to the Codelist Although there is a separate list for each of the code types—ICD-9 Dx, ICD-9 Px, ICD-10 CM,  ICD-10 PCS, CPT, and HCPCS — the procedure for adding codes to the lists is the same. You have a choice to add codes either by:

 Moving codes straight from the tabulars when searching in the Codes panel (by double-clicking the code).

 Typing codes directly into the code list.

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Add Linked Codes to the Codelist Book entries with brackets [ ] around a second code, or a plus + sign between two or more codes indicate that the codes are linked.

Some conditions require two separate codes to record both the etiology and manifestation of a disease. In the printed code books, these conditions appear with two codes after the term, the second one enclosed in brackets [ ]. The first term represents the etiology; the second term, in brackets, represents the manifestation, for example: Disease Kimmelstiel-Wilson (intercapillary glomerulosclerosis) 250.4 [581.81]

When you add the first code of a linked set to the Codelist, Clintegrity 360 | Coding and  Clintegrity 360 | Abstracting give you the option to add both of the codes. For more about linked codes,  see page 244.

Add Linked Codes from the ICD-9 Index

1. Find the term in the ICD-9 Dx Index from the Codes panel.

2. Click the first code to open the tabular at the first code, the etiology.

3. Double-click to add the code to the codelist.

Add Linked Codes from the ICD-9 Tabular

1. Find the first code (etiology) in the ICD-9 Tabular.

2. Double-click to add the code to the codelist.

Add Code Packages to the Codelist This section explains the two methods to search for Code Packages:

 From the Code Book

 From the Code Packages page

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Search Directly from the Code Book

1. Enter a term in the code book’s search field. Any existing Code Packages that contain codes from the book in which you are searching and that match the search term are listed at the bottom of the screen.

OR

Search from the Code Packages Window

1. From any Clintegrity 360 | Coding/Clintegrity 360 | Abstracting screen, click the Code Packages icon on the Codes panel to access the Code Packages screen:

Figure 242: Code Packages Search Screen

2. If you need, enter a term on which to search in the Search Terms field, and click Go.

3. Click the link of the Code Package you want to use. The Code Package screen appears:

Figure 243: Code Package Link Window

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4. Check the boxes next to the codes you want to add to your codelist.

 Codes that are not checked by default are optional.

 Codes that are checked by default and cannot be un-checked are required.

 Codes that are checked by default but can be un-checked are suggested codes.

5. Click Add Codes to add the selected codes to your codelist.

Add Codes From the Code Builder

1. From the Codes panel, click the Code Builders icon to access the list view of the Code Builder window.

Figure 244: Code Builder list View Screen

2. Click the link for the Code Builder you want to use. The appropriate code builder screen appears.

Figure 245: Code Builder Window

3. Check the checkboxes next to the appropriate building blocks. As you check a checkbox, another level of checkboxes might appear. Drill down until all the building blocks are checked for the procedure.

4. Click Calculate. This opens the Code Builder Result screen.

Figure 246: Code Builder Result Window

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5. Check the checkboxes next to the codes you want to use.

6. After selecting the codes:

 Click the <

 Click the symbol next to a code to open the CPT code book at that code’s location.

 Click the Cancel button to discard your changes.

 Click Add Codes to add the checked codes to the codelist.

Add CPT Code Modifiers to the Codelist There are two columns in the Codelist for adding CPT modifiers. However, you can add two more modifiers to any code for which modifiers are appropriate on the Procedural screen. See Entering Additional Procedure Information on page 301 for more information. CPT code modifiers are listed in the Modifiers section of the CPT tabular.

CPT modifiers are entered into the columns labeled M1 and M2.

You add a code modifier to the Codelist the same way you add a code. You can add the code modifier from the tabular by using the hyperlink entries or you can type the code modifier directly into the Codelist.

Type a CPT Code Modifier Directly Into The Codelist

1. In the Codelist, click in the modifier field next to the code that you want to modify. The modifier fields are identified as M1, M2 and so forth. The code modifier field turns yellow, and a cursor appears.

2. Type the code modifier you want to use or select one from the drop-down list - it must be a valid modifier.

3. Click somewhere else on the screen. The code modifier now modifies the code it is next to. If you get an error, you probably typed an invalid code.

Add Condition Codes You can add condition codes to both inpatient and outpatient encounters while you are coding or reviewing it. There is only one condition code field at the bottom of the screen:

Figure 247: Condition Codes

Click the Plus icon to select up to seven condition codes from the drop-down list in the fields. ( )

You can send the condition codes added in:

 Coding to Compliance during Self-Review and Auto-Populate process. You can send the condition codes added in Coding to Compliance for review during Self-Review and Auto-Populate process. The reviewer can add/update these condition codes and save the reviewed condition codes.

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 Compliance to Coding by clicking the Copy Codes from Compliance icon. ( ) You can save the encounter in Coding after getting the saved reviewed condition codes.

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Modifying Codes in the Codelist In the Codelist, you can delete codes, change the order of the codes in the lists, or change a code's description. This section discussed the following ways you can modify codes in the codelist:

NOTE: All of the following procedures apply to the codelist.

How to ...

 Move Secondary Diagnosis to Principal Diagnosis (see page 298)

 Copy a Code from the Dx List to the ADx (see page 298)

 Copy a Code from the Codelist to the Reason for Visit (see page 299)

 Delete a Code from the Codelist (see page 300)

 Change a Code Modifier (see page 300)

Move Secondary Diagnosis to Principal Diagnosis

1. Select the secondary diagnosis code from the CM/ Dx list.

2. Right-click the code. A context menu appears.

3. Select Move to Principal Diagnosis. The code is moved to the Principal Diagnosis field.

Move Secondary Procedure to Principal Procedure

1. Select the secondary code from the CPT/HCPCS list.

2. Right-click the code. A shortcut menu appears.

3. Choose Move to Principal Procedure. The code is copied to the Principal Procedure field.

Copy a Code from the Dx List to the ADx

1. Click to select the code in the Dx list.

2. Right-click the code. A shortcut menu appears.

3. Choose Copy to Admitting Diagnosis. The code is copied to the A field. A copy remains in the Dx list.

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Copy a Code from the Codelist to the Reason for Visit This option is only available for outpatient encounters and for facilities with the Display Reason for Visit Facility Preference selected. You can add up to three reasons for visit codes to the encounter

See Set Up Facility Preferences on page 53 for more information on facility preferences.

1. Right-click on a Dx code, description, or POA in the codelist, and select Copy to Reason for Visit from the context menu. The code is copied to the first open reason for visit field.

NOTE: You can also directly enter codes in the reason for visit fields.

The code was copied to the first reason for visit (R1) field.

Figure 248: Copy to the Reason for Visit Window

2. To add another reason code, right-click on a CM code, description, or POA in the codelist, and select Copy to Reason for Visit from the context menu. The code is copied to the next available reason for visit field.

3. To delete a reason for visit, right-click on the reason for visit code and select Delete Reason for Visit from the shortcut menu. When you delete a reason for visit, the other reason for visit codes are automatically moved up if field RV1 or RV2 is now empty.

Add or edit the Edit Episode Info

1. Click to select a code in the codelist.

2. Right-click the code. A context menu appears.

3. Choose Edit Episode Info to add or edit the codelist.

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4. Enter the episode information in the Edit Episode Info pop-up.

Figure 249: Example of CPT/HCPCS Edit Episode Info pop-up

5. Click the Save button. The information entered in the pop-up appears in the relevant Code Grid. NOTE: Edit Episode Info link and pop-up are applicable to PCS codes as well.

Delete a Code from the Codelist

1. Click to select a code in the Codelist.

2. Right-click the code. A context menu appears.

3. Choose Delete Row to delete a code from the Codelist.

Change a Code Modifier

1. Click to select the code modifier.

2. Type the new modifier.

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Entering Additional Procedure Information There is a method to add additional information to any ICD-10 or CPT procedure you place on the codelist - including the date of the procedure and the name of the physician who performed it.

How to ...

Enter Procedure Codes Information When you are entering an inpatient or outpatient encounter, select PX or CPT/HCPCS Code Grids buttons to view the respective Code Grids.

Figure 250: PCS Code Grids

1. On the same line with the PCS code, enter the following additional information:

Table 74: PCS Codes - Additional Fields and Descriptions

FIELD DESCRIPTION

EP Enter the episode number. (Use numbers, not text characters, so  Clintegrity Abstracting custom data is correctly exported by HL7 interface)

Date Enter the episode date or click the Calendar icon to select one from a calendar. Defaults to the Admit Date.

Time Enter the episode time.

Provider Enter the procedure provider or click the lookup icon to select one from a list.

2. On the same line with the HCPCS code, enter info into the fields, some of which are:

Table 75: HCPCS Codes - Additional Fields and Descriptions

FIELD DESCRIPTION

M1 - M4 Enter HCPCS modifiers or select them from the drop-down list.

Unit Enter the quantity for the HCPCS code.

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3. When you finish entering information, you can view different pricing scenarios. Icons in the Code panel give you the following options:

 If APC icon is selected, you can calculate APCs or view APC details.

NOTE: If you have the VIP license, then the APC icon is grayed out.

 If ASC icon is selected, you can calculate ASCs or re sequence ASCs.

ASC icon APC icon

Figure 251: APC and ASC Icons The pricing information displayed also changes when you click the APC or ASC icons.

 If the Group icon is selected, then you can view updated DRG information including flags.

NOTE: The Group icon displays only for 3M™ groupers.

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Using the Editor You cannot group the record as long as there are edit messages in your Codelist. As you code, Clintegrity 360 | Coding/Clintegrity 360 | Abstracting checks the Codelist for the following problems:

 Compatibility of the codes with the patient's age and sex

 Compatibility of the posted codes with each other

 Correct code sequence

Clintegrity 360 | Coding/Clintegrity 360 | Abstracting uses the latest Medicare code editor software to detect and report errors in coding claims data as well as proprietary correct coding edits. The following edits are included:

 Medicare Code Edits. (Marked (mce) in the Edit Messages box)

 Outpatient Code Edits. (Marked (oce) in the Edit Messages box)

 Obstetric edits

 Relational code edits based on coding conventions, instructions, and guidelines

 Data Quality check edits that prompt you to look in the medical record for information supporting a related or more specific code

Edit messages appear on the codelist screen as you post codes. Each code with an associated edit turns into red with a sequence number.

Edit box turns red

Figure 252: Using the Editor Screen

Before you can group an encounter, certain errors must be corrected while other messages are alerts only that may or may not pertain to every encounter.

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View Edit Messages A message appears when there are edit alerts for codes in the Codelist or code edit logic. The edits are defined in the Rule Settings. (See Configure Compliance OP Selection Rules ICD-10 on page 99 for more information on defining these edits.)

 Edits set up for IP Rule Settings for Incomplete encounters are triggered when you code an Inpatient encounter and save it as Incomplete.

 Edits set up for OP Rule Settings for Incomplete encounters are triggered when you code an Outpatient encounter and save it as Incomplete.

 If you change the coding status to Complete and then Save the encounter, any edits that are set under IP (or OP) Rule Settings for Complete encounters are triggered. The edits include any Regulatory or Data Quality Edits (such as MCE which include Invalid codes, Relational Code edits, or E-code edits).

How to ...

Correct Errors and Warnings

1. Click the All Errors and Warnings dialog box on the Coding screen. The Edit Messages screen appears and shows the following types of information:

 Warnings, which are designated by the warnings symbol and do not need to be corrected.

NOTE: The Errors and Warnings dialog box displays the OK button when there are only Warnings. Click OK to save the encounter with warnings.

 Errors, which are designated by the errors symbol and need to be corrected. There is no way to override errors.

NOTE: While saving, the Errors and Warnings dialog box does not display the OK button when there are Errors.

2. In the Codelist, correct the errors listed on the Edit Messages screen.

NOTE: The All Errors and Warnings dialog box displays the data preceding the edit message aligned with the first line of the edit message.

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3. Click Ignore All to ignore the messages.

NOTE: You can ignore messages at any time (it is not necessary to finish correcting errors).

The following window displays showing 0 errors and warnings on the Coding screen.

Figure 253: Ignore All Messages Window You can view the ignored messages by clicking the Show or hide ignored Messages section icon.( )

NOTE: Even if you ignore all messages, the system does not allow you to save the encounter until all errors are resolved.

 Click Close to close the window.

 Click the print icon to print out a copy of the window.

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306 Chapter 10 Grouping and Pricing

Chapter 10  Grouping and Pricing

After you fill in the Codelist, you are ready to calculate reimbursement for the encounter using Coding’s grouper. The grouper calculates the reimbursement by considering the patient’s age, sex, discharge status, discharge date, payor, and the codes for:

 The principal diagnosis

 Complications and comorbidities

 Procedures

How to ...

 Generate Reimbursement Amounts (see page 307)

 Calculate APCs (see page 307)

 View APC Detail (see page 309)

 Calculate ASCs (see page 310)

 Shuffle Codes (see page 310)

 View APR DRG Detail for a 3M™ Licensed Grouper (see page 312)

 Use Alternate DRGs (see page 314)

Generate Reimbursement Amounts DRG and RBRVS values are calculated automatically as you code.

1. Fill in all the required fields on the Patient Information banner.

2. Add all codes to the Codelist. See Adding Codes to the Codelist on page 291.

3. Address and clear all Edit messages. See Using the Editor on page 303. Once a DRG is generated it appears on the Codelist screen.

See Store and Use a Second DRG Grouper on page 318 for information on using more than one DRG Grouper.

Calculate APCs Coding/Abstracting allows APC assignments to be captured for billing purposes.

NOTE:

 Coding/Abstracting calculates APC reimbursements; grouping and pricing of outpatient encounters is dependent on your Admin\System Configuration setup. See the System Administration Guide for system configuration information.

 Clintegrity supports Community Mental Health Centers (CMHC) outlier reimbursement calculation for APCs 0172 and 0173.

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1. Fill in all the required fields on the Patient Information banner.

2. Add all codes to the Codelist. See Adding Codes to the Codelist on page 291.

3. Click the Calculate APCs icon next to the APC icon on the Codes panel. ( ) Where applicable, the APC is calculated and the APC fields on the screen are populated.

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View APC Detail Coding/Abstracting allows APC assignments to be captured for billing purposes. You can view the detail of APCs calculated for an encounter from the Procedural Info tab.

NOTE: Coding/Abstracting calculates APC reimbursements; grouping and pricing of outpatient encounters is dependent on your Admin\System Configuration setup. See the System Administration Guide for system configuration information.

Coding/Abstracting calculates APC reimbursements; grouping and pricing of outpatient encounters is dependent on your Admin\System Configuration setup.

1. Fill in all the required fields on the Patient Information banner.

2. Add all codes to the Codelist. See Adding Codes to the Codelist on page 291.

3. Click the APC Detail icon on the Codes panel. ( ) The APC Detail window appears.

Figure 254: APC Detail Screen The information on it includes:

Table 76: APC Detail Fields and Descriptions

FIELD DESCRIPTION

HCPCS The HCPCS code

Mods The HCPCS modifiers.

U(nits) The number of units for the HCPCS code.

APC The APC that relates to the HCPCS code.

PSI The Payment Status Indicator.

Rate The rate at which the reimbursement is calculated.

CoIns The CoInsurance rate for the APC.

Red. CoIns The Reduced CoInsurance rate for the APC.

Outlier Reimb The outlier reimbursement value.

% The percent paid for the APC.

Reimb The Rate less then Coinsurance.

Fac The total reimbursement to the Facility (Total of Reimbursement + Outlier Reimbursement Reimbursement).

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FIELD DESCRIPTION

Total Reimb The total reimbursement at the code level (Outlier Reimbursement + Reimbursement).

Charge The charge for the HCPCS code.

4. You can then click the Close button to close the APC Detail pop-up window and return to the encounter.

Calculate ASCs The Pricer calculates an Ambulatory Surgery Center (ASC) payment based on Physicians’ Current Procedural Terminology (CPT) codes in the patient record. CPT codes that are subject to ASC payment can fall into one of several payment groups. Prior to 2008, payment is based on the CMS rate for each ASC group. From 2008 forward, payment is based on the CMS ASC Payment Indicator. The rates are entered into Coding by your System Administrator. If any of the CPT procedures in an encounter are non-ASC procedures, the record is not subject to the ASC payment method. Out-of-Scope procedures do not affect the ASC payment.

1. Fill in all the required fields on the Patient Information banner.

2. Add all codes to the Codelist. See Adding Codes to the Codelist on page 291.

3. Click the Calculate ASCs icon on the Codes panel. ( )

Shuffle Codes Coding calculates the DRG based on all of the diagnosis and procedure codes that are entered in the record. However, when the patient’s bill is submitted to the payer, it is possible that only a subset of the codes might be used for reimbursement purposes. For example, CMS accepts a maximum of 9 diagnosis and 6 procedure codes.

Automatic Shuffling

 User preferences can be set to automatically shuffle codes as you code. See Set Up Facility Preferences on page 53 for more information. ™  If codes are shuffled by Clintegrity and then are sequenced in a different order by 3M :

 If automatic shuffle setting is not set, the codes’ new order is not altered by Clintegrity.

 If automatic shuffle setting is set, the codes are re-shuffled by Clintegrity.

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Shuffle On Demand You can perform a code shuffle to resequence the current codes. This is important in situations where a code affecting the DRG is entered but cannot be submitted to the payer due to its position.

1. Generate reimbursement DRG as described in Generate Reimbursement Amounts on page 307.

2. Click the Shuffle ICD-9 Codes or Shuffle HCPCS Codes icon, depending upon which kind of code you want to re-order. ( ) The codes are re-ordered with the most appropriate code in the first position.

Shuffle Out-of-Range Codes You get a pop-up warning, with shuffle options, if a code that impacts the DRG is out of range.

1. Click Save for an encounter when:

 Your codelist contains more than the standard number of Dx and Px codes allowed by your facility.

 One of the out-of-range codes impacts the DRG.

 Your facility’s Shuffle settings (see Set Up Facility Preferences on page 53) are set to Off.

2. The Code Shuffling Warning pops up.

Figure 255: Codes Shuffling Warning Pop-up Window

3. Click the appropriate button:

 Auto Shuffle to shuffle all ICD9 Dx and Px codes automatically and save the encounter.

 Manual Shuffle to stop the save and return you to the Codelist, where you can shuffle the codes manually. Select this option if you want to keep specific code pairs together or want to sequence codes per your facility’s coding guidelines.

 Save and Close to save the encounter as-is, with the codes in the sequence they are in.

NOTE: If there are errors and warnings while saving the encounter, then click the Save and Close button on the Codes Shuffling Warning pop-up window and then click OK on the Errors and Warnings dialog.

The cursor focus begins on Auto Shuffle; press ENTER to select it. You can tab sequentially to the other buttons, or click them with your mouse.

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View APR DRG Detail for a 3M™ Licensed Grouper Coding provides grouping of APR DRGs for those facilities with APR DRG licenses from 3M™, along with license from NUANCE for either the APR DRG Detail screen or the Abstracting 3M APR DRG™ Detail screen.

 APR-DRG data collected using the 3M APR-DRG™ grouper is stored in the Abstracting database only, and cannot be transferred to another database system.

 You access the APR-DRG Detailed information by selecting the APR-DRG Detail icon on the Coding screen in Coding—but the link is only available if your facility has purchased the 3M APR-DRG™ license.

The 3M APR-DRG™ grouper does not group automatically (as do Clintegrity groupers). To get the APR DRG values to save to the Clintegrity database, you must follow the instructions for APR DRG Detail Screen, for details about APR DRG.

APR DRG Detail Screen

1. On the Coding screen, click the 3M APR DRG Detail icon. The icon is available if: ( )

 At least one Dx code has been entered.

 The patient is an inpatient.

2. Review the APR DRG grouper information in the APR DRG Detail pop-up window: The P designation for the principal diagnosis can be in a position other than the first position. When this occurs, the code with the P designation is the diagnosis driving the DRG assignment. Sequencing of that code as the principal diagnosis is dependent on the documentation within the record.

Figure 256: APR DRG Detail Screen Window

Table 77: APR DRG Detail Fields and Descriptions

FIELD DESCRIPTION

Description APR-DRG description

MDC Major Diagnostic Category that classifies the base APR-DRG

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FIELD DESCRIPTION

APR-DRG Weight Adjusted weight based on severity.

Severity of Illness Rating of 1-4, 4 being the most severe The SOI value is also displayed on the Patient Banner.

Risk of Mortality 0 - No class specified 1 - Minor 2 - Moderate 3 - Major 4 - Extreme C - Excluded Complication of Care D - Duplicate SDX

P - Indicates a program-designated PDX X - Excluded Blank - Diagnosis was not recognized or ROM not requested. The ROM value is also displayed on the Patient Banner.

Low LOS Threshold Displays if unusually low for the DRG

High LOS Threshold Displays if unusually high for the DRG

RTC Error return for APR-DRG assignment (if any potential problems with grouping process)

3. Click Close to close the window and return to the encounter.

4. Save the encounter (after closing the APR DRG Detail pop-up) to save the APR DRG data elements to the Clintegrity database.

See APR DRG Reports on page 333 for information about running reports using APR DRG data.

NOTE: For outpatient encounters, you can group all codes by clicking the APC/EAPG Detail icon.

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Use Alternate DRGs Coding's grouper gives you more than a single DRG based on your current Codelist - it gives you a list of alternate DRGs that might also apply if you re-sequence the codes currently in the codelist. Coding’s DRG Pro goes a step further. It provides DRGs that might apply if you provide additional information about the patient encounter. For more information about DRG Pro, see DRG Pro on page 315. ( )

Click the Alternate DRG icon to view the following pop-up window.( )

Figure 257: Alternate DRG Window

Alternate DRGs are generated and listed using the following logic:

1. Each diagnosis in the codelist is reviewed as if it were the principal DX. (The current DRG uses the current PDx in the codelist.)

2. Against each possible principal, Coding checks the codelist for secondary diagnoses that might be complications or comorbidities that impact the DRG.

3. Against each combination of 1 and 2, Coding checks for procedures in the Codelist that might also affect the DRG.

Of course, if all the codes in the current codelist are correct and complete, you can simply use the first DRG that Coding provides. The DRG that applies to the current sequence of codes in the Codelist is called the current DRG. The current DRG is the only DRG that is saved with the patient record when you complete the encounter.

Once you have generated a DRG or you have selected an alternate one from the DRG screen, that DRG is current as long there are no changes in:

 The patient's age, sex, discharge status, discharge date, or payor

 The codes or their sequence

If you change any of these, the record is ungrouped.

See Store and Use a Second DRG Grouper on page 318 for information on using more than one DRG Grouper.

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DRG Pro

NOTICE: The Clintegrity DRG feature is based upon analysis of the Medicare Severity Diagnosis Related Group - (MS-DRG) for the fiscal year grouper versions utilized by the Centers for Medicare and Medicaid Services (CMS) for acute inpatient hospital reimbursement. Nuance Communications, Inc., its employees, agents, and staff make no representation or guarantee that the use of the Clintegrity DRG Pro feature prevents differences in opinions or disputes with payors as to the amounts which is paid to providers of services. Nuance, its employees, agents, and staff make no representation or guarantee that this feature is free of errors and bear no responsibility or liability for the results or consequences of its use. In compliance with ethical coding guidelines, be sure documentation supports any coding changes made to the record. If necessary, consult with the provider responsible for clinical documentation for clarification of supporting documentation.

DRG Pro provides coders a tool to help assign the appropriate MS-DRG. Whereas the Alternative DRG feature helps you analyze the possible MS-DRG groups using the codes currently assigned in the Codelist, DRG Pro prompts the coder to review the health record for potential diagnoses and procedures based on clinical relevance suggesting another MS-DRG grouping opportunity. ( )

DRG Pro reviews the assigned MS-DRG for appropriate CC/MCC opportunities or suggests an alternative MS-DRG providing a related target MS-DRGs that can apply if certain unmet conditions are fulfilled.

DRG Pro offers a suggested list (not all inclusive) of these diagnostic conditions or procedures with direct access to the code book Tabular List or ICD-10-PCS Table via code hyperlink. In the code book, applicable coding resources and clinical advice are available to review before adding codes to the patient record.

The general procedure for regrouping a patient record using DRG Pro is as follows:

1. Code the patient record and group it. See Generate Reimbursement Amounts.

2. Use DRG Pro to list target DRGs with requirements that are not currently met in the patient record.

3. If appropriate, recode the patient record to achieve the DRG, then regroup the record. CC Exclusions – Certain codes that are designated as complications or comorbid conditions and/or major complications or comorbid conditions may be excluded based on the principal diagnosis that is present and not change the DRG grouping.

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How to ...

 Use Alternate DRGs (see page 314)

 View Target DRGs and Their Requirements (see page 316)

 Find Codes That Fulfill Unmet Requirements (see page 317)

 Close the DRG Pro Window (see page 317)

 Store and Use a Second DRG Grouper (see page 318)

View Target DRGs and Their Requirements

1. After coding the patient record, click the DRG Pro icon to access the DRG Pro window. ( )

Figure 258: DRG Pro Screen

2. Select a DRG listed in the target DRGs. The Focus and Code Description sections populate with data relating to the selected target DRG.

3. Select a code in the Focus section. The codelist updates with any codes related to the selected focus.

4. Select a code in the Code Description section. Search results are shown in tabular.

5. Select the code you want to use from the tabular. The codelist updates with the new code and the DRG Pro window closes.

NOTE: You can access the ICD-9 DRG Pro functionality on the Coding (P) screen and the ICD-10 DRG Pro functionality on the Coding (S) screen.

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Find Codes That Fulfill Unmet Requirements

1. In the DRG Pro window, click to select an appropriate target DRG.

Figure 259: DRG Description Window The Focus and Code Description areas show what focuses and codes are required to use the target DRG. You can continue to click target DRGs, scanning the requirements as you go.

2. Click a focus in the Focus section.

Figure 260: DRG Focus Window The codes listed in the Code Description section change as the focus for the DRG changes. You can continue to click different focuses, scanning the requirements.

3. If appropriate, select a code in the Code Description section. Search results appear in the tabular.

4. Select the code you want to use from the tabular. The Codelist is updated with the new code and the DRG Pro window closes.

Close the DRG Pro Window Click Close to close the DRG Pro window. If you prefer, you can leave the DRG Pro window open and still work elsewhere in Coding. Just click the DRG Pro icon in the codelist to see the DRG Pro window again.

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Store and Use a Second DRG Grouper You can store, and report on, two DRG’s for a single encounter. Such an encounter with two DRGs:

 Stores in the Clintegrity database the DRG number, grouper name and grouper version

 Can be sent through RTI, HL7 and then back into Clintegrity

 Is available for reports: the Primary DRG for standard reports, the secondary DRG for reporting through ad hoc report writer

Depending on your Admin settings, if outpatients have DRG’s calculated and the payor has both a primary and secondary grouper assigned, both are calculated on the outpatient encounter also.

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Chapter 11  Reports

This section provides information to help you with:

 Processing Reports

 Schedule Reports

 Ad-Hoc Reports

 Reports by Category

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Processing Reports

How to ...

Create Reports In the Global Settings area of the Reports screen, you can set parameters for a group of reports. Each of the parameters operates independently of the others, or can be combined to limit the number of encounters considered. If you want to use different parameters for different reports, you must make separate requests for each, or run each report separately.

CAUTION: Consider issues of confidentiality when running reports. The user’s access level might be lower than the confidentiality levels of patients who appear on a report. For example, patients with a confidentiality level of 4 could appear on a report run by a user with an access level of 1.

1. Select Coding/Abstracting\Reports to open the Reporting page.

Figure 261: Coding Reports Screen

2. Select the category for the type of report you want to run by clicking the report type link on the left-hand side of the screen. Depending on the report category you select, the global report options vary. For instance, in Productivity Reports and Coding Summary, you can select Date Coded information.

3. For HL7 reports, select the Send Date range (this is the only global option for HL7 reports). For Productivity reports, select a Date Coded range. For APC, DRG, Physician Coding, and Custom Coding reports, select the Admit and Discharge dates for the report. You can choose one of the two types of report dates:

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 To define a time period, click Specific Dates and fill in the dates for the beginning and end of the period, for example, 06/01/2005 to 06/30/2005. (All dates must be entered in this format MM/DD/YYYY.)

 To use a predefined time period (for example, Today, Last Week, Last Month), click Relative Dates and select a time period from the Date Range drop-down list.

See Relative Date Examples on page 323.

4. Select a Facility to report by clicking the facility name in the list.

5. Select the coding statuses on which you want to report.

 If you have set up custom Coding or Abstracting statuses (see page 85), you can run reports on those status. (Custom statuses are not displayed in the selection box unless an encounter has had that custom status applied.)

 If you do not select a status, all statuses are reported on.

6. Select a primary coder on whom to report.

7. Select the primary payors you want on the report. The Primary Payor list box displays the description of the primary payor along with the primary payor’s ID.

The primary payor’s description also appears with the ID.

Figure 262: Global Settings Screen

NOTE: The Primary Payor list box setting applies only to APC and EAPG reports.

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8. Check the checkbox next to the Report Name label to select all the reports of that kind, or check the checkbox next to the name of the report you want to run. You can select more than one report at a time. This example shows the APC Reports page with APC Frequency report selected:

Figure 263: Report Name and Sort By Window

 The Report Name section shows reports specific to the Report Category you select from the on the left of the screen. Select a different category, and a different set of reports becomes available under Report Name.

9. Choose the report parameters for the report you selected.

 If the report you choose has a sort option, choose one from the Sort By drop-down list next to the reports you are running.

 If the report you choose has a category list, use the default selection of All, or limit the categories to report on.

 If the report you choose has a secondary sort option, select it from the Secondary Sort drop-down list that appears when you check the checkbox next to the report name.

10. After you finish selecting the report parameters, you can:

 Click the Preview button to preview the report before it prints. The Report Preview screen appears.

 Click the Print button to print the report either before or after previewing it.  Preview it, then re-select the report parameters and preview the new results.

 Click the Schedule button to run the Report Scheduler. The form view of the Schedule Setup screen appears. See Set Report Schedule for instructions on using the Report Scheduler.

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Relative Date Examples Relative dates are predefined dates relative to the date the request is made. For example, if today’s date is September 11, 2014, selecting one of the relative dates corresponds with the following start and end dates:

Table 78: Relative Dates and Examples

RELATIVE DATE START DATE END DATE

Today 09/11/2014 09/11/2014

Yesterday 09/10/2014 09/10/2014

Last Week (last week from Sun to Sat.) 09/02/2014 09/08/2014

Last Month 08/01/2014 08/31/2014

MTD 06/01/2014 09/11/2014

Last 3 months 06/01/2014 06/31/2014

Last 6 months 03/01/2014 03/31/2014

Last Calendar Year 01/01/2013 12/31/2013

Calendar YTD 01/01/2014 06/07/2014

Fiscal YTD 01/02/2014 06/07/2014

Last Fiscal Year 01/02/2013 01/01/2014

Schedule Reports Use Report Scheduler to create and run a group of reports that you run on a regular basis. You can schedule the group to run on a particular day or time; you can have the report output printed, saved to a file, and e-mailed in one of several different formats.

You schedule reports when you create them. See Create Reports for information on report creation.

NOTE: If you upgrade your version of Clintegrity, you need to re-schedule the reports if either:  A report was not sortable prior to the upgrade and is sortable after.  A report was sorted by a column that is no longer available to sort by after the upgrade.

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How to ...

 Set Report Schedule(see page 324)

 Edit Schedule(see page 325)

 View Schedule History(see page 326)

Set Report Schedule

1. Select Coding/Abstracting\Reports\Report Scheduler to open the list view of the Schedules.

Figure 264: Report Scheduler Screen

2. From this screen you can:

 Click the name under the Schedule column to open and edit that report schedule. See Edit Schedule for instructions.

 Click a name under the Report Name column to open and edit the parameters for an individual report in a schedule. See Create Reports for instructions.

 Click a File link to view the Report Schedule History. See View Schedule History for instructions.

 Delete a report schedule by checking the box at the end of the report schedule’s line and clicking the Delete button.

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Edit Schedule

1. If you choose to edit a report schedule, the Schedule Setup form screen opens.

Figure 265: Report Schedule Screen

 To edit an existing schedule, select its name from the Schedule Name drop-down list.

 To create a new report schedule, click the Add New button and fill in the Schedule Name field with its name.

2. Fill in the remaining fields in the Report Schedule section of the screen:

Table 79: Report Schedule Fields and Descriptions

FIELD DESCRIPTION

Schedule Name The name of the schedule.

Schedule Start Time The time and day the report starts to run. Enter Time in the format HH:MM and date in the format: mm/dd/yyyy.

Facility Select the facility that the report schedule is for. NOTE: You are able to view only the scheduled reports for the facilities that are assigned to you.

Time Zone Select the time zone in which the report will run.

Schedule Cycle Select the report frequency; for example, daily or monthly.

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3. The report output can be either printed out, sent to a recipient via e-mail or saved to a file. In the bottom section of the screen, you can choose any or all of these delivery methods:

Table 80: Print Schedule Fields and Descriptions

FIELD DESCRIPTION

Print Check this box to print reports on the network printer of the facility to which the report schedule is assigned. To use the Print feature, it must be set up in Admin\Preferences\Network Printer. NOTE: You can now select multiple facilities for report print scheduling.

Email Check this box to mail the report to the recipients you specify in the To field.

File Check this box to save the report in the format or formats you choose. To use the File feature, it must be setup in the Admin\Preferences.

4. Click the Save button to save your changes or click Reset to discard your changes.

View Schedule History

1. On the Report Schedule screen, click the link in the File column to open the Report Schedule History, which:

 Shows the date on which a report was run.

 Gives you access to the report as Text, PDF or Excel files.

Figure 266: View Schedule History Window

2. To delete a report schedule history entry, uncheck the checkbox at the end of the report’s run date line and click the Delete button.

3. Click the Back to Report Schedule link to return to the main Report Schedule screen.

NOTE: You need to manually change the font color for headers in the Excel downloaded Scheduled reports.

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Ad-Hoc Reports Ad-Hoc or custom reports can be created and added to Clintegrity user menus. These reports run and operate like any other Clintegrity report.

In addition, permissions for individual Ad-Hoc reports can be granted. Ad-Hoc reports for which you do not have access appear grayed out and cannot be selected. You can be assigned the Print and/or the Schedule permissions. The Print and Schedule buttons appear in the Ad-Hoc report area, however based on your assigned permission either may be hidden.

Select multiple options using ICD-9 and ICD-10 picklists

Figure 267: Ad-Hoc Report Name Selection Screen

Contact your System Administrator to obtain permission to Ad-Hoc reports if needed.

How to ...

 Create, or change, an Ad-Hoc Report(see page 327)

 Run the Ad-Hoc Reports(see page 327)

 Schedule Reports(see page 328)

Create, or change, an Ad-Hoc Report

1. Open JReports and create or change the Ad hoc report.

2. Copy the new report into the Coding/Abstracting directory so that the report can be run from within Coding/Abstracting.

Run the Ad-Hoc Reports

1. Select Coding\Reports to access the Report page.

2. Click Ad-Hoc.

3. Click the Refresh button to populate the Report list with Ad Hoc reports created or updated in the Coding/Abstracting directory.

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4. Enter the following criteria:

a. Facilities - Optionally, select the facilities you want, to appear on the report. By default, all facilities are included on the report. To add a facility, click the facility in the Available list and then click the right arrow to move the user to the Selected list. To remove a facility, click the facility name in the Selected list and then click the left arrow to move it to the Available list.

b. Report Format - Optionally, select the report format. By default, PDF is selected.

c. Select the report by clicking the checkbox(es) to the left of the Report Name.

5. After you finish selecting the report parameters you can:

a. Click the Preview button to preview the report before it prints. The Report Preview screen appears.

b. Click the Print button to print the report either before or after previewing it.

c. After previewing it, re-select the report parameters and preview the new results.

d. Click the Schedule button to run the Report Scheduler. The form view of the Schedule Setup screen appears. See Set Report Schedule for instructions on using the Report Scheduler.

Schedule Reports Use Report Scheduler to create and run a group of reports that you run on a regular basis. You can schedule the group to run on a particular day or time; you can have the report output printed, saved to a file, and e-mailed in one of several different formats. You schedule reports when you create them.

How to ...

 Set Report Schedule

 Edit Schedule

 View Schedule History

Set Report Schedule

1. Select Coding/Abstracting\Reports\Report Scheduler to open the list view of the schedules. From this screen you can:

a. Click the name under the Schedule column to open and edit that report schedule. See Edit Schedule for instructions.

b. Click a name under the Report Name column to open and edit the parameters for an individual report in a schedule. See Create, or change, an Ad-Hoc Report for instructions.

NOTE: If you upgrade your version of Clintegrity, you need to re-schedule the reports if either:  A report was not sortable prior to the upgrade and is sortable after.  A report was sorted by a column that is no longer available to sort by after the upgrade.

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c. Click a File link to view the Report Schedule History. See View Schedule History for instructions.

d. Delete a report schedule by checking the box at the end of the report schedule's line and clicking the Delete button.

Edit Schedule

1. If you choose to edit a report schedule, the Schedule Setup form screen opens.

a. To edit an existing schedule, select its name from the Schedule Name drop-down list.

b. To create a new report schedule, click the Add New button and fill in the Schedule Name field with its name.

2. Fill in the remaining fields in the Report Schedule section of the screen:

a. Schedule Start Time: The time and day the report starts to run. Enter Time in the format HH:MM and date in the format: mm/dd/yyyy.

b. Facility: Select the facility that the report schedule is for.

c. Time Zone: Select the time zone in which the report will run.

d. Schedule Cycle: Select the report frequency; for example, daily, or monthly.

3. The report output can be either printed out, sent to a recipient via e-mail or saved to a file. In the bottom section of the screen, you can choose any or all of these delivery methods.

4. Click the Save button to save your changes or click Reset to discard your changes.

View Schedule History

1. On the Report Schedule screen, click the link in the File column to open the Report Schedule History, which:

a. Shows the date on which a report was run.

b. Gives you access to the report as Text, PDF, or Excel files.

2. To delete a report schedule history entry, clear the checkbox at the end of the report’s run date line and click the Delete button.

3. Click the Back to Report Schedule link to return to the main Report Schedule screen.

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Reports by Category

 Encounter Reports(see page 330)

 APC Reports(see page 330)

 EAPG Reports(see page 331)

 DRG Reports(see page 331)

 Productivity Reports(see page 332)

 Physician Coding Reports(see page 332)

 Custom Coding Reports(see page 332)

 HL7 Database Reports(see page 333)

 Coding Summary Report(see page 333)

 Encounter Status Reports(see page 333)

 APR DRG Reports(see page 333)

Encounter Reports The following reports are accessed from the drop-down list in the upper right-hand corner of the encounter entry screen.

 Billing Form – This report summarizes all the codes, grouping and reimbursement values in an encounter.

 Coding Summary – This report summarizes all the codes and grouping information in an encounter.

 Physician Attestation – This report summarizes all the codes and grouping information in an encounter with a line for the physician’s signature.

 Abstracting Summary – This report summarizes all abstracting information on an encounter

APC Reports

 APC Case Level Detail – Sorts APCs by frequency of occurrence from the highest to the lowest with a subset by the patient’s account number. The patient subset follows each APC sort.

 APC Frequency – Sorts APCs by frequency of occurrence from the highest to the lowest occurrence.

 CPT Frequency by APC – Sorts APCs by frequency of occurrence from the highest to the lowest with a subsort by CPT code.

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EAPG Reports

 CPT Frequency by EAPG – Sorts EAPGs by frequency of occurrence from the highest to the lowest with a subsort by CPT code.

 EAPG Case Level Detail – Sorts EAPGs by frequency of occurrence from the highest to the lowest with a subset by the patient’s account number. The patient subset follows each EAPG sort.

 EAPG Frequency – Sorts EAPGs by frequency of occurrence from the highest to the lowest occurrence.

DRG Reports

 Case Mix Index – Can be used to spot outliers that might affect the facility’s Case Mix Index. Case Mix Index Summary report provides total number of records and case mix.

 DRG Analysis – Details basic DRG information for each account and notes differences between actual LOS versus GMLOS and actual charges versus DRG reimbursement. It is grouped by facility and displayed with ICD-9 data followed by ICD-10 data.

NOTE: * is displayed in between Account # and DRG columns for ICD-9 related rows.

 DRG Listing Report – Contains DRG, description, weight, GMLOS, AMLOS and reimbursement for all DRGs for a CMS grouper. Federal Rate Table information is used to calculate the reimbursement. Specialized groupers (AP Grouper, Wisconsin and such) cannot be printed through this report.

 DRG Revisions – Shows encounters, by coder, that were changed and the reimbursement impact of the change. The report presents the initial DRG, determined prior to the use of DRG PRO and the Alternative DRG feature, and the final/saved DRG. The report includes relevant patient demographic data, the initial and final DRG, DRG description, weight, reimbursement, and the difference in reimbursement between the two DRGs.

 POA Frequency - This report allows the user to view the POA values assigned to each diagnosis, per encounter. POA values impact the calculated DRG in some grouping systems, namely, in CMS version 26 and later. When the encounter contains Hospital Acquired Conditions (HACs) determined by the POA value, the grouper may exclude it while calculating the DRG. This exclusion will then affect the pricing, excluding it from reimbursement.

NOTE: If no active exempt value exists, the system assumes the facility is using no value and leaves the field blank. As of 1/1/2011, Blank is a valid value that can be reported for Exempt POA. For an Exempt Diagnosis code, if a POA value has been entered incorrectly, the system removes the invalid value, replacing it with a Blank.

 DRG Frequency – Sorts DRGs by frequency of occurrence from the highest to the lowest.

 Comparative Analysis Report – This report is based on the DRG Frequency Report. It compares ICD-9 to ICD-10 account detail on encounter for the most frequent assigned ICD-9 DRG’s.

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Productivity Reports

 Activity Log – Lists activity by factors such as Provider, Coder, DRG, or Payor. It is grouped by facility and displayed with ICD-9 data followed by ICD-10 data.

NOTE: * is displayed in between Account # and DRG columns for ICD-9 related rows.

 Code Edit – This report is a tool to be used by HIM Management to monitor and track, by the Primary coder, cases that are finalized, but still have outstanding or unresolved Code Edit messages. The information presented includes relevant patient demographic, ICD-9 codes, HCPCS/CPT, DRG, DRG Descriptions, and the Edit Messages that were overridden.

 Productivity Detail – Lists details of encounters coded by an individual coder as well as summary information about the number of encounters and codes, and average coding time. Coder’s productivity can be analyzed by factors such as Payor or Total Coding Time. You can set both primary and secondary sorts on this report.

 Productivity Summary – Lists summary data for individual codes by patient type. Includes information about the number of encounters, codes, and average coding time.

 ICD-10 PSI Edits – Lists summary data of those encounters with ICD-10 codes and PSI Edits. The triggered PSI Edits are mentioned against the encounters listed.

Physician Coding Reports

 E/M Audit Report – This report is a tool to track the components selected by a coder to assign an E/M Code.

 E/M Coding Frequency – E/M Code Frequency Report sorts E/M codes by frequency of occurrence from the highest to the lowest and includes provider, reimbursement and visit type category and sub-category.

Custom Coding Reports

 Synonyms – Generates a report of all the synonyms in the Clintegrity 360 | Coding system.

 Smartips – Generates a report of all the Smartips added by a specified user in the Clintegrity Coding system.

 Code Packages – Generates a report of all the Code Packages in the Clintegrity 360 | Coding system.

 Alternate Descriptions – Generates a report of all the Alternate Descriptions in the  Clintegrity 360 | Coding system.

 ICD-10 Alternate Descriptions – Generates a report of all the ICD-10 Alternate Descriptions in the Clintegrity 360 | Coding system.

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HL7 Database Reports HL7 CIE Report describes about all the rejected records and successful records entry within specified HL7 message date criteria. HL7 CIE Report is generated through CIE engine.

 Rejected Records (CIE) - The HL7 Rejected Records Report shows records that have been rejected by Clintegrity for the specified date range..

 Outbound Records (CIE) - The HL7 Outbound Records Report shows successful outbound records from Clintegrity for the specified date range.

Coding Summary Report

 Coding summary – Summarizes all codes and grouping information in an encounter. It generates separate reports for ICD-9 and ICD-10 as per the code version selected in Global Settings.

Remote Grouper Reports

 This report summarizes all the remote grouping information related to any grouper that has been accessed from an encounter. This report is applicable for all inpatient and outpatient encounters.

NOTE: User should have APR license to access this report

Encounter Status Reports

 Record Status – Generates a report of all encounters in a particular Coding or Abstracting status.

APR DRG Reports

 APR DRG Frequency – Shows trends in APR DRG usage and can be sorted by DRG, Coder, Provider or Discharge Date.

 APR DRG Detail – Shows data by individual encounters. It can be sorted by DRG, number of encounters, or average weight.

 PPC Frequency – Allows you to review the PPC grouper data. It can be sorted by PPC, PPC Group, PPC Level.

 PPC Case Level Detail – Allows you to review the PPC grouper data. It can be sorted by Account Number, MRN, Admitting APR DRG, Discharge APR DRG.

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334 Appendix A Physician Coding

Appendix A  Physician Coding

Overview Physician Coding is a knowledge-based encoding solution which includes full text of all the officially required code books that are used for pro-fee services coding. The knowledge-based approach of Physician Coding complies with the official ICD-9 CM and ICD-10 CM & CPT Guidelines for coding. As Physician Coding uses the same entries and formats as that of the official books, the user does not have to learn any new coding methods.

It is a very essential tool designed for physician offices that helps doctors to accurately document, code, and bill for their services in an easy to use format. This ensures appropriate reimbursement, reduces the chances of inappropriate Medicare billing and allows for better patient care.

The Physician Coding system stores multiple visits for a single patient, maintaining information such as what was diagnosed and coded. The centralized encounter management of Physician Coding updates the common data element values as they are changed in any Clintegrity application. If an encounter remains open in any application, it can be viewed in ‘Read Only’ mode in all other Clintegrity applications.

This section provides you information about:

 Components (see page 336)

 Admin Setup (see page 336)

 Preferences Setup (see page 336)

 Viewing Edit Messages (see page 337)

 Setting up Physician Encounter (see page 339)

 Coding the Physician Record (see page 340)

 Adding Codes from the E & M Code Builder (see page 342)

 Entering Additional Procedure Information (see page 347)

 Modifying Codes in the Codelist (see page 350)

 Reports (see page 354)

 Glossary (see page 355)

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Components Physician Service Coding is made up of the following major components:

 Complete text of the volumes in a familiar format:  ICD-9-CM and ICD-10-CM  Physicians’ Current Procedural Terminology (CPT®)

 Additional entries to help coding

 Physician Coding Editor: The Editor checks for accurate coding consistent with standard coding principles, guidelines and watches for potential errors and ambiguous coding issues.

 ASC grouper

Admin Setup

As a System Administrator, you must do the user security settings such as add, maintain or delete Users and Groups. You also grant particular permissions to groups and include or exclude users from particular groups. For more information on user security settings, you can refer to the Users / Security chapter of the System Administration Guide.

As a System Administrator, you must also do the system configurations for Facility, Provider and Payor. You set up the system tables that contain all the information used in encounters. To view system tables, you must have specific System Administration privileges. To modify or add system table information, you must have System Configuration privileges for All Facilities. For more information on system configurations, you can refer to the System Configuration chapter of System Administration Guide.

Once you configure and create Facility, Provider and Payor, you create a new Visit Type – Physician. To create a new Physician, click the Add New button on Admin / Visit Type screen and select the Physician radio button to map the new Visit Type to Physician Patient Type. The new Physician Visit Type gets a Visit Type ID – P, by default.

Preferences Setup Once you do the Admin Setup, you can set up the User, Facility and Global Preferences, custom coding variables, and encounter field properties.

If your account is connected to an HIS system for the facility IP/OP account, the global preferences feature provides the ability to link up the accounts by either Patient Name and DOB or by MRN.

To set up the Complete and Incomplete Coding Edits for the Physician type, refer to About Rule Settings. You must verify if the edits are set to Error, Warning or Ignore.

You cannot group the record as long as there are edit messages in the Codelist. As you code, the application checks the Codelist for the following problems:

 Compatibility of the codes with the patient's age and sex.

 Compatibility of the posted codes with each other.

 Correct code sequence

336 Appendix A Physician Coding

The application uses the latest coding principles and guidelines implicit in ICD-10 and CPT, as well as those issued by the American Hospital Association's Central Office on ICD-9 and the Centers for Medicaid and Medicare Services. The following edits are included:

 Medicare Code Edits. (Marked (mce) in the Edit Messages box)

 Outpatient Code Edits. (Marked (oce) in the Edit Messages box)

 Obstetric edits

 Optimizing edits that alert you to other codes, usually complications and comorbidities, that would result in different DRGs

 Quality check edits that prompt you to look in the medical record for information supporting a related or more specific code

Edits and quality checks appear on the Codelist screen as you post codes. Each code with an associated edit appears with a red sequence number.

Edit messages appear in the Edit Message A red field box. background number indicates a code with Edit messages.

Before you can group an encounter, you must address all edit messages by correcting any errors.

Viewing Edit Messages A message appears when there are edit messages for codes in the Codelist. These errors can be generated by errors in coding or by field date entries. The edits are defined in the Rule Settings. For more information on defining these edits, refer to Configure Compliance OP Selection Rules on page 96.

 Edits set up for IP Rule Settings for Incomplete encounters are triggered when you code an Inpatient encounter and save it as Incomplete.

 Edits set up for OP Rule Settings for Incomplete encounters are triggered when you code an Outpatient encounter and save it as Incomplete.

 If you change the coding status to Complete and then Save the encounter, any edits that are set under IP (or OP) Rule Settings for Complete encounters are triggered. The edits include any Regulatory or Data Quality Edits (such as MCE which include Invalid codes, Relational Code edits, or E-code edits).

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How To Correct Errors and Warnings Regardless of from where the errors are generated, you must correct them before the encounter can be grouped:

1. Click the All Errors and Warnings link. The Edit Messages screen appears and shows the following types of information:

 Warnings, which are designated by the warnings symbol and do not need to be corrected.

 Errors, which are designated by the errors symbol and need to be corrected. There is no way to override errors.

 Comments for LCD data display in the comments section.

2. In the Codelist, correct the errors listed on the Edit Messages screen.

NOTE: The All Errors and Warnings pop-up window displays the data preceding the edit message aligned with the first line of the edit message.

Figure 268: Errors and Warnings pop-up

3. When you finish correcting the errors, you can:

 Click Close to close the window.

 Click the print icon to print out a copy of the window.

338 Appendix A Physician Coding

Setting up Physician Encounter To begin setting up a Physician Encounter:

1. Click Add New Physician button on the Coding / Abstracting > View Encounters screen.

Figure 269: Add New Physician button

2. Enter the Patient MRN. If MRN is not available, you must create a new patient by clicking the Look Up icon.

Figure 270: Physician Information screen

3. To create a new patient, click Add New button on the Select a Patient pop-up window.

4. Fill the mandatory fields in the Patient Information section and enter the MRN in the Facility Information section. Click Save to save the new Patient.

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5. Verify the Patient Type displays Physician, once the new Physician patient is created. Fill the mandatory fields in all the sections on the screen.

6. Fill the Primary Payor ID field in the Financial Information section to fire LCD/NCD Edits.

7. Click Save to save the Physician encounter.

Coding the Physician Record The Patient Information screen for the patient type Physician offers certain features specific to the patient type.

HCPCS Codes You can enter specific HCPCS code details for encounters with a patient type of Physician.

 Add the HCPCS code to the Codelist by double-clicking it or pressing ENTER. If you do not know the code, you can search for it and then enter it, following the process at Search for a Code From the Codelist.

 Select up to four modifiers for each HCPCS code.

 Enter the provider name or use the lookup pop-up to choose one. For information on sorting these fields by provider name, refer to Filter by Provider, (see page 341)

 Enter a service date or use the calendar pop-up to choose one.

 Enter the number of units used.

 Enter a Dx code line number to which to link the HCPCS code.

 The Fees calculate automatically

 Check the box if the line item is Complete and ready for billing. Refer to Line Item Billing, (see page 341).

340 Appendix A Physician Coding

The RBRVS values are calculated automatically as you code. To see the RBRVS parameters, click the Display RBRVS link at the bottom of the Coding screen.

For more information, refer to Generate Reimbursement Amounts, (see page 307).

Filter by Provider To display only the HCPCS codes assigned to a certain provider, select the provider’s name from the Provider’s drop-down box.

You can bill the provider’s line items separately. Refer to Line Item Billing, (see page 341).

Line Item Billing You can bill each physician service line-by-line, whether or not the status of the encounter as a whole is complete or incomplete.

1. Filter the list of provider by selecting a provider from the drop-down list.

2. When you have completed the data on any line, check the Completed box at the end of the line.

3. When you save your work on the encounter (even if the entire encounter is incomplete), the checked line item is billed.

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If you need to re-bill the line item, right-click your mouse in the line, then select Resend Bill from the pop-up menu.

Adding Codes from the E & M Code Builder When you are creating an encounter with a patient type of Physician, you can add codes from the Evaluation and Management (E & M) Calculator. The E/M Calculator link is enabled after a Dx code is entered on the Codelist.

If a physician assigned an E/M code to an encounter, it can be captured in the Physician Assigned E/M Code field of the Coding screen. The system does not validate the code, because the field is intended primarily for quality control.

1. Click the E/M Code builder link on the Codelist screen or choose it from the Q Link menu to access the Calculate E/M Code screen.

Figure 271: E/M Code Builder The Calculate E/M Code screen is dynamic, meaning the items available in the drop-down lists change depending upon the items selected in the previous drop-down list. Each of the following scenarios show the different options available to arrive at the correct E/M code.

2. Select a Visit Type category from the drop-down lists

IF YOU SELECT... CONTINUE AT...

 Consultations  Visit Type, Scenario A, (see page 342)  Home Services  Visit Type, Scenario A, (see page 342)  Hospital Inpatient Services  Visit Type, Scenario A, (see page 342)  Nursing Facility Service  Visit Type, Scenario A, (see page 342)  Office or Outpatient Services  Visit Type, Scenario A, (see page 342)  Domiciliary, Rest Home or Custodial Care  Visit Type, Scenario B, (see page 343)  Emergency Department Services  Visit Type, Scenario B, (see page 343)  Hospital Observation Services  Visit Type, Scenario B, (see page 343)  Preventive Medicine Services  Visit Type, Scenario B, (see page 343)  Preventative Medicine  Visit Type, Scenario C, (see page 344)

Visit Type, Scenario A For any of the following Visit Types:

342 Appendix A Physician Coding

 Consultations

 Home Services

 Hospital Inpatient Services

 Nursing Facility Service

 Office or Outpatient Services

Follow these steps:

1. Check, if true, the box that says Greater than 50% of the time spent was face to face with physician counseling and/or coordination of care. If not true, go to step 3.

2. If you check the box, the field Total Face to Face time appears. You must enter more than 15 minutes to generate an E/M code.

3. Click the Next button to calculate the E/M Code. The code is displayed in a pop-up window.

Figure 272: Calculated E/M Code

4. Click Save. The pop-up window closes and the HCPCS field is populated with the code.

Visit Type Scenario B For any of the following Visit Types:

 Domiciliary, Rest Home or Custodial Care

 Emergency Department Services

 Hospital Observation Services

 Preventive Medicine Services

Follow these steps:

343 Clintegrity Coding/Abstracting User Guide

1. Select a Visit Type Subcategory from the drop-down list.

2. Select a Guideline from the drop-down list.

 If you choose 1995 Guidelines, click Next.  The History expandable list contains the options relating to History of Present Illness; Review of Symptoms; and Personal History, Family History and Social History.  The 1995 Guidelines Examination expandable list contains options relating to Body Area and Organ systems.  The Medical Decision Making list contains the options relating to Diagnosis Problem Types, Data Elements and Complexity Level.

 If you choose 1997 Guidelines, choose an exam type from the drop-down list:

 The History expandable list contains the options relating to History of Present Illness; Review of Symptoms; and Personal History, Family History and Social History.  The Exam Type expandable list contains options relating to Body Area and Organ systems. (Specific options depend upon the exam type chosen on the previous screen).  The Medical Complexity expandable list contains options relating to Diagnosis Problem Types, Data Elements, and Complexity Level.

3. Click Calculate to calculate the E/M Code. The code is displayed in a pop-up window.

4. Click Save. The pop-up window closes and the HCPCS field is populated with the code.

Visit Type, Scenario C For the Preventive Medicine Visit type, follow these steps:

1. Select a Visit Type Subcategory from the drop-down list.

2. Select a Guideline from the drop-down list.

3. Select an age range from the Age drop-down list. Click Next.

4. Expand the Anticipatory Guidance list and check the Anticipatory Guidance checkbox.

5. Expand the Risk Factor Reduction Intervention list and check the Risk Factor Reduction Intervention checkbox.

6. Click Calculate to calculate the E/M Code. The code is displayed in a pop-up window.

7. Click Save. The pop-up window closes and the HCPCS field is populated with the code.

344 Appendix A Physician Coding

E&M Calculation Confirmation Upon calculation confirmation, you can print or print to file and also reprint from the E/M Audit Report in the Physician Coding Reports.

Figure 273: E/M Calculation Confirmation window

E/M Code populates the CPT/HCPCS field from the E/M Calculator.

Right-click on the CPT/HCPCS code and the context menu displays the Medical Necessity Policy when it is available. Access the Medical Necessity pop-up window to view a policy on a code even when an edit has not been triggered.

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Medical Necessity Policy Example

Figure 274:

Figure 275: Medical Necessity Policy Example

Smartips for Physician Coding Smartips for Physician Service Related Coding are marked with P.

Figure 276: Physician Coding Smartips

For information regarding Smartips, refer to Smartips, (see page 255).

346 Appendix A Physician Coding

Entering Additional Procedure Information There are two methods to add additional information to any ICD-9 or CPT procedure you place on the Codelist—including the date of the procedure and the name of the physician who performed it. You can select the Procedure Info link from the View Encounters secondary navigation, or you can enter the information in the Episode Info pop-up window. Both methods are described here.

How to ...

 Enter Procedural Info (see page 347)

 Edit Episode Info (see page 349)

 Copy Previous Episode Info (see page 350)

Enter Procedural Info When you are entering an inpatient or outpatient encounter, select the Procedural Info link from the View Encounters secondary navigation menu. The Procedural Information screen appears. For each encounter, Px codes are in the upper grid and HCPCS codes in the lower grid.

Figure 277: Encounters Procedural Information

347 Clintegrity Coding/Abstracting User Guide

1. On the same line with the Px code, enter the following additional information:

FIELD DESCRIPTION

EP Enter the episode number. (Use numbers, not text characters, so Abstracting custom data is correctly exported by HL7 interface)

Date Enter the episode date or click the Calendar icon to select one from a calendar. Defaults to the Admit Date.

Provider Enter the procedure provider or click the lookup icon to select one from a list.

2. On the same line with the HCPCS code, enter info into the fields, some of which are:

FIELD DESCRIPTION

M1 - M4 Enter HCPCS modifiers or select them from the drop-down list.

Unit Enter the quantity for the HCPCS code.

Rev Enter the revenue code for the HCPCS code.

Charge Enter the charge for the HCPCS code.

APC Enter the APC that relates to the HCPCS code.

PSI The Payment Status Indicator.

Rate The rate at which the reimbursement is calculated.

% Reimb The percent paid for the APC.

3. When you finish entering information, you can view different pricing scenarios.

Links at the lower right-hand corner of the code list give you options:

 If APC is selected, you can calculate APCs or view APC details.

 If ASC is selected, you can calculate ASCs or re sequence ASCs.

APC link: ASC link:

Figure 278: APC and ASC Link

348 Appendix A Physician Coding

The pricing information displayed also changes when you click the APC or ASC link.

Edit Episode Info

1. In the Codelist, click the Px or CPT code for which you want to enter more information.

2. Right-click the code.

3. On the shortcut menu that opens, select Edit Episode Info to open the Episode Info screen. The HCPCS Episode Info screen shows modifier information; the Px Episode Info screen does not.

Figure 279: Edit Episode Info pop-up

4. Click any field or press TAB until the cursor is in the field you want to edit.

5. Type in the information in the Episode Info fields, some of which are:

FIELD DESCRIPTION

Code Shows the procedure code selected in the Codelist. This field is not editable.

Modifiers The modifiers for the code. These only appear for HCPCS codes.

Units The number of units of the HCPCS item used.

Episode A number assigned to a surgical episode. Repeating the episode number duplicates the associated date and provider ID. You can change these if necessary. NOTE: Use numbers (not text characters) to ensure that Abstracting custom data is correctly exported by the HL7 interface.

Provider A unique identifier for the provider who performed the procedure. To see the provider lookup table, click the lookup icon. .

6. Press ENTER after typing in a field or press TAB to move to the next field.

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7. When you are finished entering information, you can click Cancel to discard your changes and close the pop-up window, or Save to save your changes and close the pop-up window.

Copy Previous Episode Info You can copy information—such as date and provider—from one procedure code line into the next new PX code line:

1. In the Codelist, enter the Px or CPT code you want to add to the encounter.

2. Right-click on the code.

3. On the shortcut menu that opens, select Copy Previous Episode Info. The code is added to the codelist, with the existing data from the previous line of code (if the information exists), such as episode number, date, provider, units of service.

NOTE: Units of service field accept numbers with up to three decimal points.

After you fill in the Codelist, you can go ahead with calculating the reimbursement for the encounter. The grouper calculates the reimbursement by considering the patient’s age, sex, discharge status, discharge date, payor, and the entered codes. For information on grouping and reimbursement calculation, see Grouping and Pricing, (see page 307).

Modifying Codes in the Codelist In the Codelist, you can delete codes, change the order of the codes in the lists, or change a code's description. This section discussed the following ways you can modify codes in the codelist:

NOTE: All of the following procedures apply to both the Codelist and Quick List unless otherwise specified.

How to ...

 Change a Code's Description in the Codelist (see page 351)

 Copy a Code from the ADx to the PDx (see page 351)

 Move Secondary Diagnosis to Principal Diagnosis (see page 351)

 Copy a Code from the Dx List to the ADx (see page 351)

 Copy a Code from the Codelist to the Reason for Visit (see page 352)

 Delete a Code from the Codelist or Quick List (see page 352)

 Delete All Codes From the Dx, Px, or CPT lists (see page 352)

 Duplicate a Procedure Code (see page 353)

 Change the Order of Codes Within a List (see page 353)

 Change a Code Modifier (see page 353)

 Copy a Code Modifier (see page 353)

350 Appendix A Physician Coding

Change a Code's Description in the Codelist If you have permission, you can change a code’s description for the encounter on which you are working.

1. In the Codelist, click to select the description you want to change.

 Click once to select the entire description. Then type the replacement description.

 Click twice to insert a text cursor between letters. You can then use the arrow keys or the mouse to move the cursor for more detailed editing.

2. Edit the description. You can select and edit parts of it as in any text box. If the entire description is selected, anything you type replaces the entire description.

3. Press ENTER or TAB to move out of the field or click anywhere else on the screen.

4. If you decide to delete your new description, the original description populates in the field.

Your new description is stored in the Codelist. However, this description does not affect the standard description. If you plan to use the description again, you might want to create an Alternate Description, which would be permanently available to you.

Copy a Code from the ADx to the PDx

1. Click to select the code in the A field.

2. Right-click the code. A shortcut menu appears.

3. Choose Insert as Primary Diagnosis. The code is copied to the PDx. A copy remains in the ADx field.

Move Secondary Diagnosis to Principal Diagnosis

1. Click to select the secondary code in the Dx list.

2. Right-click the code. A shortcut menu appears.

3. Choose Move to Principal Diagnosis. The code is copied to the Principal Diagnosis field.

Copy a Code from the Dx List to the ADx

1. Click to select the code in the Dx list.

2. Right-click the code. A shortcut menu appears.

3. Choose Copy to Admitting Diagnosis. The code is copied to the A field. A copy remains in the Dx list.

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Copy a Code from the Codelist to the Reason for Visit This option is only available for outpatient encounters and for facilities with the Display Reason for Visit Facility Preference selected. You can add up to three reasons for visit codes to the encounter. For more information on Facility Preferences, refer to Set Up Facility Preferences.

1. Right-click on a Dx code, description, or POA in the Codelist, and select Copy to Reason for Visit from the shortcut menu. The code is copied to the first open reason for visit field.

NOTE: You can also directly enter codes in the reason for visit fields.

The code was copied to the first reason for visit (R1) field.

2. To add an additional code, right-click on a Dx code, description, or POA in the Codelist, and select Copy to Reason for Visit from the shortcut menu. The code is copied to the next available reason for visit field.

NOTE: If all of the reason for visit fields are filled, the Copy to Reason for Visit option is grayed out (unavailable).

3. To delete a reason for visit, right-click on the reason for visit code and select Delete Reason for Visit from the shortcut menu. When you delete a reason for visit, the other reason for visit codes are automatically moved up if field R1 or R2 is now empty.

Delete a Code from the Codelist or Quick List

1. Click to select a code in the Codelist.

2. Right-click the code. A shortcut menu appears.

3. Choose Delete Dx/Px/HCPCS Row to delete a code from the Codelist or choose Delete Code to delete a code from the Quick List. When you move the cursor out of the field, the code is deleted.

Delete All Codes From the Dx, Px, or CPT lists This procedure can only be used for codes within a single list, either Dx, Px, or CPT.

1. Click to select a code in the Codelist.

2. Right-click the code. A shortcut menu appears.

3. Choose Clear All Dx/Px/HCPCS Codes. The codes are deleted from the Codelist.

352 Appendix A Physician Coding

Duplicate a Procedure Code

1. Click to select a code in the Codelist.

2. Double-click the code to highlight it.

3. Press CTRL+C.

4. Click in the field where you want to copy the code. The cursor appears in the field.

5. Press CTRL+V. Note that duplicates always use the standard code description, even if you changed it for the original.

You cannot place duplicate ICD-9 Dx codes in the Codelist.

Change the Order of Codes Within a List

1. Put the cursor over the move arrow icon for the line of the code you want to move. A move arrow icon appears.

2. Keeping the mouse button pressed, move the code up or down in the Codelist to its new position.

3. Release the mouse button.

4. The code appears in the Codelist in its new position.

Codes cannot be moved to a grayed-out line. If you move it to one, the code appears in the last filled line in the list.

Change a Code Modifier

1. Click to select the code modifier.

2. Type the new modifier.

Copy a Code Modifier You can use copy-and-paste wherever you can select text in a text box or field.

1. Click to select the code modifier.

2. Press CTRL+C.

3. Click in the field where you want to copy the modifier. The cursor appears in the field.

4. Press CTRL+V.

References You can access Code Books, Code Packages and References links from the Physician Coding screen. For information on Code Books, see Using the Code Books, for information on Code Packages refer to Codelist chapter, and for information on References refer to Coding Setup.

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Reports You can access Physician Coding Reports from Coding / Abstracting > Physician Coding Report.

 E/M Audit Report – This report is a tool to track the components selected by a coder to assign an E/M Code.

 E/M Coding Frequency – E/M Code Frequency Report sorts E/M codes by frequency of occurrence from the highest to the lowest and includes provider, reimbursement and visit type category and sub-category.

354 Appendix A Physician Coding

Glossary

The below table lists all the important terms and its definitions that you must know:.

Term Definition

Admitting Diagnosis The patient’s condition or disease recorded at the time of admission that is utilized as a basis for examination and treatment.

ADT Admission Discharge Transfer

APR-DRG (All Patient Refined Diagnosis 3M developed APR DRGs in 1990 to address both severity of Related Groups) illness and risk of mortality over all patient populations. The APR DRG system is comprised of a clinical model and four severity of illness and risk of mortality subclasses for each base APR DRG. These subclasses are broken down into four levels (1–4): minor, moderate, major, and extreme. APR DRGs are used by hospitals for internal quality improvement and by many states for public reporting.

APC (Ambulatory Payment A payment classification system designed by CMS to explain the Classifications) type and amount of resources used during a visit to any ambulatory setting (e.g., same day surgery, emergency, and clinic). Services assigned to specific APCs share similar clinical characteristics and resource usage patterns. The classification system is based on the HCPCS Level I and II codes, CPT procedure codes and ICD-9-CM diagnosis codes submitted on UB billing forms.

eAPG (enhanced Ambulatory Patient An outpatient prospective payment system developed by CMS Groups) and 3M Health Information Systems. It is a Case Mix System, which forms the basis for federal ambulatory care reimbursement. A group of similar outpatient procedures encounters or ancillary services that are combined based upon a patient’s clinical characteristics and expected resource consumption. An APG is assigned based upon the review of ICD-9-CM codes, CPT procedure codes, patient age, sex and disposition.

Bundling The pairing of HCPCS codes that cannot be billed for the same patient on the same date of service because one code is a component of the other. See also CCI and NCCI.

CAC Computer-Assisted Coding

Charges The published prices of services provided by a facility. CMS requires hospitals to apply the same schedule of charges to all patients regardless of the expected source of payment.

CC/MCC Complication and Comorbidity/Major Complication and Comorbidity.

CDI Clinical Document Improvement

CMI Case Mix Index is the average reimbursement factor for a hospital.

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Term Definition

CMS Center for Medicare and Medicaid Services

Coding A mechanism for identifying and defining provider’s and facility’s services. Coding provides universal definitions and recognition of diagnosis, procedures and level of care used for billing and data analysis.

Documentation The written records of the provider’s encounter with the patient. It includes what the provider did and why it was done. The documentation is typically recorded in a chart and is considered by Medicare, CMS and the OIG as the “final word” on what was done and why. “If it is not documented, it did not happen” according to the Federal Government.

Encounter A summary of services rendered to a patient (inpatient and outpatient). Each encounter is reviewed by the system to validate data used in encounter submission. An encounter may include many health care encounters for a patient. This would occur when treating a patient on a “series basis” – someone who is treated at a healthcare facility for physical therapy, occupational therapy, etc. on a repeated basis (i.e., 2-3 times a week).

E&M (Evaluation and Management A section within the CPT classification system that defines the Codes) level of service provided to the patient by a provider. The incorrect assignment or over utilization of an E&M code can trigger a Medicare audit. The medical record must contain documentation to support the assignment of a level of service code.

HAC Hospital Acquired Condition

HC/HCC Hierarchical Condition Categories

HR Hierarchical Condition Categories, Medication Related

ICD-9 International Classification of Disease, Ninth Revision

ICD-10 International Classification of Diseases, Tenth Revision

Interlink A module developed by Clintegrity to enable the communication between external HIS systems and the applications developed by Nuance’s Clinical Documentation group. It provides bi-directional data feed to and from the HIM applications.

Medical Necessity A relational screening algorithm included in national and local review policies to ensure that all ordered services and procedures are medically necessary (require supportive documentation) in order for Medicare to cover the service. The algorithm will compare the reported ICD-9 diagnosis code (reported by the ordering provider) and the service or procedure ordered (HCPCS code) to the established listings of diagnosis and procedure combinations that national and local policies deem medically necessary.

MCE (Medicare Code Editor) Those code edits are established by Medicare to detect and report errors in the coding of inpatient encounters data.

356 Appendix A Physician Coding

Term Definition

MEDPAR (Medicare Provider Analysis and This file contains historical records for all Medicare hospital Review File) inpatient discharges. This data is utilized to evaluate possible DRG classification changes and to recalibrate the DRG weights.

MS-DRG Medicare Severity – Diagnosis Related Group

Modifiers 2 digit alpha, number or alpha-numeric codes that are attached to a CPT or HCPCS code when it is submitted to normal billing rules or an unusual circumstance involved in the treatment of a patient. CPT modifiers are always 2 numeric characters, HCPCS modifiers are either 2 alphas or an alpha and a numeric character. Modifiers are usually added to or changed annually. Incorrect use or lack of use of modifiers is typically sited by payers as one of the most common reason for rejected or under paid encounters.

OCE (Outpatient Code Editor) These code edits are established by Medicare to detect and report errors in the coding of outpatient encounter data.

Outpatient Services Services or procedures performed on patients that have not been admitted to the hospital. These services may be performed in a hospital or clinic that is part or affiliated with a hospital. Providers and other ancillary service providers sometimes bill portions of these services as professional services.

Patient Type Classification of patient by encounter type: Inpatient, Outpatient, Physician.

POA (Present On Admission) The purpose of the POA indicator is to differentiate between conditions present at admission and conditions that develop during an inpatient admission. POA data will be used to trace the development of infections and other conditions in patients once admitted to the hospital. The goal is to assess when conditions occur or develop.

Principal Diagnosis The condition established after study by healthcare providers to be chiefly responsible for the patient’s visit to the provider and/or facility for care. The principal diagnosis has an effect on the length of stay and the resources used to treat the patient.

Principal Procedure A procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or that was necessary to treat a complication.

Professional Services Procedures and services (or in some cases components of procedures or services) for which the provider or other service provider (chiropractor, nurse practitioner, and physical therapist) is paid. For example: when a provider performs a laceration repair in her office, she is paid for the entire procedure as a professional service. When a provider performs a laparoscopy in a hospital, he is paid only part of the fee as a professional component and the hospital is paid the other portion as a technical component (also sometimes called a facility fee).

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Term Definition

RAC (Recovery Audit Contractor) The Centers for Medicare & Medicaid Services (CMS) has taken the next steps in the agency’s comprehensive efforts to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program by awarding contracts to four permanent Recovery Audit Contractors (RACs) designed to guard the Medicare Trust Fund. The goal of the recovery audit program is to identify improper payments made on claims of health care services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Health care providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills Medicare Parts A and B.

Secondary (other) Diagnosis All conditions that co-exist at the time of admission, develop subsequently, or that affect the treatment received or length of stay. Any diagnoses that are not treated during the current hospitalizations are not to be included on the patient’s profile or on the UB.

Sequencing The arranging of ICD, CPT and HCPCS codes on the UB or CMS 5010 form for correct reimbursement. Most carriers will pay 100% of the allowable fee for the 1st procedure code listed on encounter form and a lesser% of the additional procedure codes listed. Practices that fail to list the procedure with the highest RVU first will lose revenues that they are legitimately entitled to.

Shuffling The billing forms for many payers will only accept a limited number of diagnoses and procedures. If a number of diagnoses and procedures performed exceed the limit then a health care provider may legitimately obtain a higher reimbursement by “shuffling” some of the performed diagnoses and procedures off the bill and moving others onto it.

SOI/ROM Severity of Illness / Risk of Mortality

TRICARE A regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. f/k/a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

Unbundling Coding a single all-inclusive service as several separate services, especially when done as a means of increasing reimbursement. Unethical and possibly fraudulent.

Visit Type Classification of visit that can be user defined in set up by a unique ID such as: Emergency room, Cardiology, Observation, etc.

358 Appendix B Keyboard Shortcuts

Appendix B  Keyboard Shortcuts

This section provides some quick keyboard strokes that help you perform common tasks quickly.

CAUTION: Keyboard shortcut settings already enabled on your computer supersede these Clintegrity keyboard shortcuts. For instance, if your computer is set to perform a screen rotation when you press ALT+CTRL+ARROW key, the Clintegrity command for ALT+CTRL+ARROW key is deactivated in favor of the screen rotation.

 Code List Navigation Keyboard Shortcuts (see page 359)

 General Navigation Keyboard Shortcuts (see page 360)

 Working in Code Books Keyboard Shortcuts (see page 361)

 Coding View Keyboard Shortcuts (see page 361)

 Date Keyboard Shortcuts (see page 362)

 Navigation Keyboard Shortcuts (see page 362)

Code List Navigation Keyboard Shortcuts

Table 81: Code List Navigation Keyboard Shortcuts

CODE LIST NAVIGATION KEYBOARD SHORTCUTS

CTRL + SHIFT + O To put focus on the code list search code type drop-down

CTRL + SHIFT + T To go to the first Code Grid button

CTRL + ALT + G To put focus on the grid first editable/active field

UP ARROW, DOWN ARROW To navigate the grid columns

UP ARROW, DOWN ARROW To navigate field columns on all code grids and to put focus in the next field in direction of arrow and the field that is open for edit

UP ARROW or DOWN ARROW, To navigate Smart Search suggestions and select a term or code then ENTER

SHIFT + LEFT ARROW To highlight value and allow type over ability (only when focus is in a field with a value)

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CODE LIST NAVIGATION KEYBOARD SHORTCUTS

TAB When focus is on the first Code Grid button, and TAB is pressed, focus moves to next button. When focus is on the last Code Grid button, and TAB is pressed, focus moves to the Search Type drop-down. When focus is inside the Code Grid TAB can be used to navigate within the Code Grid.

SHIFT + TAB To move focus backwards within the Codes Panel. When focus is on the first Code Grid button, the focus moves backwards within the Code Grid.

General Navigation Keyboard Shortcuts

Table 82: General Navigation Keyboard Shortcuts

GENERAL NAVIGATION KEYBOARD SHORTCUTS

ALT + DOWN ARROW To display the drop-down options

CTRL + ALT + i To access Edit Done in patient info bar

CTRL + ALT + 1, then ENTER To put focus on the Forms icon and then use tab to navigate remaining

UP ARROW or DOWN ARROW, To navigate the context menu options or to navigate the drop-down then ENTER options; press ENTER to choose the selected option

CTRL + M To open the context menu with focus on first item on the list. Press  UP ARROW or DOWN ARROW to navigate and press ENTER to select

CTRL and + (Plus Sign) To zoom in the interface

CTRL and - (Minus Sign) To zoom out the interface

TAB To move focus forward from field to field within each section

SHIFT + TAB To move focus backward from field to field

CTRL + SHIFT + / To go to the first Code Grid button from Cancel or Save sections.

ALT + O To cancel changes to the encounter in the Coding screen

ENTER When focus is on any of the Code Grid buttons and ENTER is pressed, the Code Grid is shown/hidden. When any Code Grid opens the focus is on the manual entry row.

360 Appendix B Keyboard Shortcuts

Working in Code Books Keyboard Shortcuts

Table 83: Working in Code Books Keyboard Shortcuts

WORKING IN CODE BOOKS KEYBOARD SHORTCUTS

These shortcuts work for both Coding and Compliance:

LEFT ARROW or RIGHT ARROW To collapse tree, expand tree (index or tabular)

UP ARROW or DOWN ARROW To move up or down (index or tabular)

PAGE UP or PAGE ARROW To move quickly up or down in index and tabular

ENTER, in index To move from index to tabular

For example, ALT+M, then ENTER opens Smartips.

Focus must be on a code that shows an appropriate icon—Code Builder, Smartip, Instructional Notes, Coding Clinic, or Clinical Indicator

ENTER, in Tabular Add a code from tabular to code list

CTRL + SHIFT + C To close Code Books that display in the panel only after focus is out of the code books

Coding View Keyboard Shortcuts

Table 84: Coding View Keyboard Shortcuts

CODING VIEW KEYBOARD SHORTCUTS

View Encounter, Coding, Additional Information pages

ALT + G To put focus on Abstracting Status drop-down list when you are in the Abstracting screen

ALT + DOWN ARROW To display drop-down options when focus is on a field that uses drop-down. Press UP ARROW or DOWN ARROW to move up or down the list

ALT + M To move focus to Physician Assigned E/M Code field in the Physician encounter

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Date Keyboard Shortcuts

Table 85: Date Keyboard Shortcuts

DATE KEYBOARD SHORTCUTS

Type one of the following to enter today’s date, or a date in the past or future. Then press TAB to  populate the field with the date.

T To enter today’s date

T - n Where n is the number of days in the past

T + n Where n is the number of days in the future

Navigation Keyboard Shortcuts

Table 86: Navigation Keyboard Shortcuts

WORKING IN CODE BOOKS KEYBOARD SHORTCUTS

These shortcuts work for the View Encounter List screen

ALT + T, then ENTER Reports

ALT + S, then ENTER Setup

362 Appendix C Keywords for Standard and Custom Forms

Appendix C  Keywords for Standard and Custom Forms

This appendix contains samples of the Clintegrity 360 | Coding standard form and the keywords used on those forms, as well as the keywords you can use to customize forms. You can view the forms by clicking the Forms icon on the Coding screen. ( )

NOTE: Forms are displayed based the license and whether it is relevant to the selected encounter.

It may be possible to use keywords other than those examples shown here.

 Standard Forms and Keywords:

 Coding Summary Form (see page 364)

 ICD-10 Coding Summary Form (see page 371)

 ICD-10 Inpatient Billing Form (see page 375)

 ICD-10 Outpatient Billing Form (see page 379)

 ICD-10 Physician Attestation Form (see page 383)

 Inpatient Billing Form (see page 388)

 Outpatient Billing Form (see page 394)

 Physician Attestation Form (see page 399)

 ICD-10 Physician Billing Form (see page 407)

 Physician Query Form (see page 412)

 Abstracting Summary Form (see page 418)

 ICD-10 Abstracting Summary Form (see page 425)

 Abstracting Summary Form (see page 418)

 ICD-10 Abstracting Summary Form (see page 425)

 General Keywords (see page 430)

 Encounter Keywords (see page 431)

See Creating and Printing Forms on page 196 for instructions on creating the forms.

363 Clintegrity Coding/Abstracting User Guide

Standard Forms and Keywords

Coding Summary Form

Figure 280: Coding Summary Form

364 Appendix C Keywords for Standard and Custom Forms

Coding Summary Form General Keywords The following general keywords can be used on this form:

Table 87: Coding Summary Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with the hospital {HOSPADDR2} name keyword, the data for these lines is taken from {HOSPADDR3} the Hospital Address fields in Administrative System Options. Of note, the data in these fields can include {HOSPADDR4} information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

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Coding Summary Form Encounter Keywords The following encounter keywords can be used on this form:

Table 88: Coding Summary Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ADMDX} Admission Dx Inserts Admission Dx listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx is available.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date and code description, this keyword also inserts additional Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX+FLAG} Px Code Description and Lists all procedure codes listed on the encounter procedure code flag Coding tab, including sequence number, code and code description and code flag. If no procedure codes have been listed the system leaves this blank.

366 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPX+FLAG+INFO} Px Code Description and In addition to the entire sequence number, code and Modifier + Procedure code description, this keyword also inserts additional Flag + Date and Surgeon columns to include modifier, procedure code flag, procedure date, and surgeon.The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname. If no Principal procedure is listed the system leaves this blank.

{ALLPX + INFO} Px Code Description and In addition to the entire sequence number, code and Modifier + Date and code description, this keyword also inserts additional Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Fee Inserts two fields to include ASC Group and ASC Fee. Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

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KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{BILLINFO} Units + Dx Link and Fees This single keyword inserts the number Units, Dx Link and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} DRG Inserts the primary DRG code and DRG descriptions assigned to the encounter.

{DRG} DRG Inserts the primary DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Reimbursement The keyword includes the primary DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS} GMLOS Inserts the DRG (primary) GMLOS assigned to the encounter. If not GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} MDC Inserts the DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

368 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{POA+CC+SOI+ROM+ALLDX} POA + CC + SOI + ROM In addition to the code and description, this keyword + DX Code and also includes the CC, SOI and ROM values for the Description individual code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{POA+SOI+ROM+ALLDX} POA + SOI + ROM + DX In addition to the code and description, this keyword Code and Description also includes the SOI and ROM values for the individual code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPX+FLAG} Principal Procedure Code Inserts the Principal Procedure Code from the Coding and the associated flag tab column in position 1, if known. The system leaves this blank if no PPx is available.

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KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PPXDESC+FLAG} Description of the Inserts the Principal Procedure code and the coding Principal Procedure Code flag description from the coding tab column in position and associated flag 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

370 Appendix C Keywords for Standard and Custom Forms

ICD-10 Coding Summary Form

Figure 281: ICD-10 Coding summary Form

ICD-10 Coding Summary Form General Keywords The following general keywords can be used on this form:

Table 89: ICD-10 Coding Summary Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

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ICD-10 Coding Summary Form Encounter Keywords The following encounter keywords can be used on this form:

Table 90: ICD-10 Coding Summary Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence number, POA code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 PCS + Date and Surgeon code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints all and description Reason for Visits coded, or leaves blank if none have been coded.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{PPCS} PPCS Code Inserts the ICD-10 PCS principal procedure code from the Coding tab column in position 1, if known. The system leaves this blank if no PPCS is available.

372 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PPCSDESC} Description Inserts the ICD-10 PCS principal procedure description from the Coding tab column in position 1, if known. If no PPCS code is listed the system leaves this blank.

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence number sequence number and and code. Clintegrity prints the Reason for Visits coded, code or leaves blank if none have been coded.

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS assigned to the DRG encounter. If AMLOS is not available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and DRG its Description descriptions assigned to the encounter.

{DRGREIMBURSEMENT_1 Final Reimbursement Includes the primary Final DRG for the ICD-10 grouper 0} for ICD-10 grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS assigned ICD-10 DRG to the encounter. If GMLOS is not available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC assigned to DRG the encounter. If the DRG MDC is not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

You can view or print the coding summary after completing the coding.

373 Clintegrity Coding/Abstracting User Guide

How to ...

Print the ICD-10 Coding Summary If you have completed coding, follow these steps to print the Coding Summary:

1. Select Coding Summary Form from the drop-down available at the top right-hand corner of the code books page.

2. Click the Print icon to print the coding summary. You can also click the Preview icon to view the coding summary. A sample Coding Summary Form is shown below:

Figure 282: Coding Summary Form Window - Sample

3. Since the data is not saved in this product, you will need to manually delete the codes before moving on to the next training scenario.

374 Appendix C Keywords for Standard and Custom Forms

ICD-10 Inpatient Billing Form

Figure 283: ICD-10 Inpatient Billing Form

ICD-10 Inpatient Billing Form General Keywords The following general keywords can be used on this form:

Table 91: ICD-10 Inpatient Billing Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

375 Clintegrity Coding/Abstracting User Guide

ICD-10 Inpatient Billing Form Encounter Keywords The following encounter keywords can be used on this form:

Table 92: ICD-10 Inpatient Billing Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence POA number, code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence POA number, code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon CPT code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

376 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon PCS code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints and description all Reason for Visits coded, or leaves blank if none have been coded.

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS DRG assigned to the encounter. If AMLOS is not available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and its Description DRG descriptions assigned to the encounter.

{DRGREIMBURSEMENT_10} Final Reimbursement Includes the primary Final DRG for the ICD-10 for ICD-10 grouper grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS ICD-10 DRG assigned to the encounter. If GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC DRG assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

377 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{PPCS} PPCS Code Inserts the ICD-10 PCS principal procedure code from the Coding tab column in position 1, if known. The system leaves this blank if no PPCS is available.

{PPCSDESC} Description Inserts the ICD-10 PCS principal procedure description from the Coding tab column in position 1, if known. If no PPCS code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number and number and code. Clintegrity prints the Reason for code Visits coded, or leaves blank if none have been coded.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

378 Appendix C Keywords for Standard and Custom Forms

ICD-10 Outpatient Billing Form

Figure 284: ICD-10 Outpatient Billing Form

ICD-10 Outpatient Billing Form General Keywords The following general keywords can be used on this form:

Table 93: ICD-10 Outpatient Billing Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

379 Clintegrity Coding/Abstracting User Guide

ICD-10 Outpatient Billing Form Encounter Keywords The following encounter keywords can be used on this form:

Table 94: ICD-10 Outpatient Billing Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence POA number, code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon CPT code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

380 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon PCS code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints and description all Reason for Visits coded, or leaves blank if none have been coded.

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS DRG assigned to the encounter. If AMLOS is not available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and its Description DRG descriptions assigned to the encounter.

{DRGREIMBURSEMENT_10} Final Reimbursement Includes the primary Final DRG for the ICD-10 for ICD-10 grouper grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS ICD-10 DRG assigned to the encounter. If GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC DRG assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

381 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{PPCS} PPCS Code Inserts the ICD-10 PCS principal procedure code from the Coding tab column in position 1, if known. The system leaves this blank if no PPCS is available.

{PPCSDESC} Description Inserts the ICD-10 PCS principal procedure description from the Coding tab column in position 1, if known. If no PPCS code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number and number and code. Clintegrity prints the Reason for code Visits coded, or leaves blank if none have been coded.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

382 Appendix C Keywords for Standard and Custom Forms

ICD-10 Physician Attestation Form

Figure 285: ICD-10 Physician Attestation Form

383 Clintegrity Coding/Abstracting User Guide

ICD-10 Physician Attestation Form General Keywords The following general keywords can be used on this form:

Table 95: ICD-10 Physician Attestation Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

384 Appendix C Keywords for Standard and Custom Forms

ICD-10 Physician Attestation Form Encounter Keywords The following encounter keywords can be used on this form:

Table 96: ICD-10 Physician Attestation Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence POA number, code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon PCS code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints and description all Reason for Visits coded, or leaves blank if none have been coded.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

385 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS DRG assigned to the encounter. If AMLOS is not available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and its Description DRG descriptions assigned to the encounter.

{DRGREIMBURSEMENT_10} Final Reimbursement Includes the primary Final DRG for the ICD-10 for ICD-10 grouper grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS ICD-10 DRG assigned to the encounter. If GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC DRG assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

386 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{PPCS} PPCS Code Inserts the ICD-10 PCS principal procedure code from the Coding tab column in position 1, if known. The system leaves this blank if no PPCS is available.

{PPCSDESC} Description Inserts the ICD-10 PCS principal procedure description from the Coding tab column in position 1, if known. If no PPCS code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number and number and code. Clintegrity prints the Reason for code Visits coded, or leaves blank if none have been coded.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

387 Clintegrity Coding/Abstracting User Guide

Inpatient Billing Form

Figure 286: Inpatient Billing Form

388 Appendix C Keywords for Standard and Custom Forms

Inpatient Billing Form General Keywords The following general keywords can be used on this form:

Table 97: Inpatient Billing Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

389 Clintegrity Coding/Abstracting User Guide

Inpatient Billing Form Encounter Keywords The following encounter keywords can be used on this form:

Table 98: Inpatient Billing Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ADMDX} Admission Dx Inserts Admission Dx listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx is available.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

390 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} Final DRG and Inserts the Final DRG code and DRG descriptions Description assigned to the encounter.

{DRG} Final DRG Inserts the Final DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Final Reimbursement The keyword includes the Final DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS} Final GMLOS Inserts the Final DRG GMLOS assigned to the encounter. If not GMLOS is not available the system leaves this blank.

{INITIAL_DRG + Initial DRG and its Inserts the Initial DRG code and DRG descriptions DRGDESC} Description assigned to the encounter.

{INITIAL_DRG} Initial DRG Inserts the Initial DRG code assigned to the encounter.

{INITIAL_DRGREIMBURSE Initial Reimbursement The keyword includes the Initial DRG reimbursement MENT} amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated.

{INITIAL_GMLOS} Initial GMLOS Inserts the Initial DRG GMLOS assigned to the encounter. If no GMLOS is available the keyword on the form will display as blank.

{INITIAL_MDC} Initial MDC Inserts the Initial DRG MDC assigned to the encounter.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} Final MDC Inserts the Final DRG MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

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KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{POA+CC+SOI+ROM+ALL POA + CC + SOI + In addition to the code and description, this keyword DX} ROM + DX Code and also includes the CC, SOI and ROM values for the Description individual code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{POA+SOI+ROM+ALLDX} POA + SOI + ROM + In addition to the code and description, this keyword DX Code and also includes the SOI and ROM values for the individual Description code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

392 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

393 Clintegrity Coding/Abstracting User Guide

Outpatient Billing Form

Figure 287: Outpatient Billing Form

Outpatient Billing Form General Keywords The following general keywords can be used on this form:

Table 99: Outpatient Billing Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

394 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

Outpatient Billing Form Encounter Keywords The following encounter keywords can be used on this form:

Table 100: Outpatient Billing Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ADMDX} Admission Dx Inserts Admission Dx listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx is available.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

395 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

396 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

397 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

398 Appendix C Keywords for Standard and Custom Forms

Physician Attestation Form

Figure 288: Physician Attestation Form

399 Clintegrity Coding/Abstracting User Guide

Physician Attestation Form General Keywords The following general keywords can be used on this form:

Table 101: Physician Attestation Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

400 Appendix C Keywords for Standard and Custom Forms

Physician Attestation Form

Figure 289: Physician Attestation Form

401 Clintegrity Coding/Abstracting User Guide

Physician Attestation Form General Keywords The following general keywords can be used on this form:

Table 102: Physician Attestation Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

402 Appendix C Keywords for Standard and Custom Forms

Physician Attestation Form Encounter Keywords The following encounter keywords can be used on this form:

Table 103: Physician Attestation Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

403 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

404 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} DRG Inserts the primary DRG code and DRG descriptions assigned to the encounter.

{DRG} DRG Inserts the primary DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Reimbursement The keyword includes the primary DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS} GMLOS Inserts the DRG (primary) GMLOS assigned to the encounter. If not GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} MDC Inserts the DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

405 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

406 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

ICD-10 Physician Billing Form

CM label CM link

Figure 290: ICD-10 Physician Billing Form

Physician Billing Form General Keywords The following general keywords can be used on this form:

Table 104: Physician Billing Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

407 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

Physician Billing Form Encounter Keywords The following encounter keywords can be used on this form:

Table 105: Physician Billing Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

408 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

409 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

410 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

411 Clintegrity Coding/Abstracting User Guide

Physician Query Form

Figure 291: Physician Query Form

412 Appendix C Keywords for Standard and Custom Forms

Physician Query Form General Keywords The following general keywords can be used on this form:

Table 106: Physician Query Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

413 Clintegrity Coding/Abstracting User Guide

Physician Query Form Encounter Keywords The following encounter keywords can be used on this form:

Table 107: Physician Query Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

414 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

415 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} DRG Inserts the primary DRG code and DRG descriptions assigned to the encounter.

{DRG} DRG Inserts the primary DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Reimbursement The keyword includes the primary DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS} GMLOS Inserts the DRG (primary) GMLOS assigned to the encounter. If not GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} MDC Inserts the DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

416 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

417 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

Abstracting Summary Form

Figure 292: Abstracting Summary Form

418 Appendix C Keywords for Standard and Custom Forms

Abstracting Summary Form General Keywords The following lists the general keywords that can be used on the form:

Table 108: Abstracting Summary Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

Abstracting Summary Form Encounter Keywords The following lists the encounter keywords that can be used on the form:

Table 109: Abstracting Summary Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ADMDX} Admission Dx Inserts Admission Dx listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx is available.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

419 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX + POA+SOI+ROM} Dx Code + Description In addition to the code and description, this keyword + SOI + ROM + POA also includes the SOI and the ROM values for the individual code and the POA value. These additional values will appear to the right of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

420 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{APGINFO} EAPG, EAPG Type, Inserts four fields per HCPCS code. Used with EAPG Category, and {ALLCPT} type keywords, since EAPG values are code EAPG Rate related and usually display along with corresponding CPT code. This information is only available for outpatient encounters.

{APGRATE} EAPG Rate Includes the EAPG Rate for the EAPG assigned to the HCPCS code. If the EAPG Rate in not available leave it blank.

{APGREIMBURSEMENT} Total EAPG Includes the Total calculated EAPG Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total EAPG Reimbursement is available the system leaves this blank.

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

421 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} Final DRG and its Inserts the primary Final DRG code and DRG Description descriptions assigned to the encounter.

{DRG} Final DRG Inserts the primary Final DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Final Reimbursement The keyword includes the primary Final DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{DRG_ROM} ROM for the encounter The encounter level ROM value. This value can be added to other keywords to add encounter level ROM to a specific line. For example, {DRG + Description} + {DRG_ROM} prints the DRG number, the DRG Description and the encounter level ROM.

{DRG_SOI} SOI for the encounter The encounter level SOI value. This value can be added to other keywords to add encounter level SOI to a specific line. For example, {DRG + Description} + {DRG_SOI} prints the DRG number, DRG Description and the encounter level SOI.

{GMLOS} Final GMLOS Inserts the Final DRG (primary) GMLOS assigned to the encounter. If GMLOS is not available the system leaves this blank.

{INITIAL_DRG + Initial DRG and its Inserts the primary Initial DRG code and DRG DRGDESC} Description descriptions assigned to the encounter.

{INITIAL_DRG} Initial DRG Inserts the primary Initial DRG code assigned to the encounter.

422 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{INITIAL_DRGREIMBURSE Initial Reimbursement The keyword includes the primary Initial DRG MENT} reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement information is not available the keyword on the form displays as blank.

{INITIAL_GMLOS} Initial GMLOS Inserts the Initial DRG (primary) GMLOS assigned to the encounter. If no GMLOS is available the keyword on the form displays as blank.

{INITIAL_MDC} Initial MDC Inserts the Initial DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the keyword on the form displays as blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} Final MDC Inserts the Final DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

423 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

424 Appendix C Keywords for Standard and Custom Forms

ICD-10 Abstracting Summary Form

Figure 293: ICD-10 Abstracting Summary Form

ICD-10 Abstracting Summary Form General Keywords The following general keywords can be used on this form:

Table 110: ICD-10 Abstracting Summary Form General Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

425 Clintegrity Coding/Abstracting User Guide

ICD-10 Abstracting Summary Form Encounter Keywords The following encounter keywords can be used on this form:

Table 111: ICD-10 Abstracting Summary Form Encounter Keywords

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ABSTRACTINGSTATUS} Abstracting Status Inserts the abstracting status for that encounter. This will never be blank.

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence POA number, code and description, this keyword also lists POA to the right of the diagnosis description

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon CPT code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

426 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 + Date and Surgeon PCS code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints and description all Reason for Visits coded, or leaves blank if none have been coded.

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS DRG assigned to the encounter. If AMLOS is not available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} Final DRG and its Inserts the primary Final DRG code and DRG Description descriptions assigned to the encounter.

{DRGREIMBURSEMENT} Final Reimbursement The keyword includes the primary Final DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and its Description DRG descriptions assigned to the encounter.

{DRGREIMBURSEMENT_10} Final Reimbursement Includes the primary Final DRG for the ICD-10 for ICD-10 grouper grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

427 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS ICD-10 DRG assigned to the encounter. If GMLOS is not available the system leaves this blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC DRG assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATNAME} Patient Name Inserts the patient’s name. Lastname, firstname, middleinitial.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{PPCS} PPCS Code Inserts the ICD-10 PCS principal procedure code from the Coding tab column in position 1, if known. The system leaves this blank if no PPCS is available.

{PPCSDESC} Description Inserts the ICD-10 PCS principal procedure description from the Coding tab column in position 1, if known. If no PPCS code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

428 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number and number and code. Clintegrity prints the Reason for code Visits coded, or leaves blank if none have been coded.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

429 Clintegrity Coding/Abstracting User Guide

General Keywords The following lists the general keywords that can be used on the form:

Table 112: General Keywords and Descriptions

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{TODAY} Today’s Date Inserts the current date at the left margin. The information for this field is taken from the current system date of your computer.

{HOSPNAME} Hospital Name This keyword enters the name of your hospital into your letter. The name appears exactly as it was entered in the Hospital Name field of Administrative System Options.

{HOSPADDR1} Address Lines 1-5 There are five separate keywords available to enter each line of your hospital address. As with {HOSPADDR2} the hospital name keyword, the data for these {HOSPADDR3} lines is taken from the Hospital Address fields in Administrative System Options. Of note, the {HOSPADDR4} data in these fields can include information other than the actual street address. For example, the last line might include the hospital’s telephone number or e-mail address.

{USERID} User ID Inserts the ID of the person currently logged into the workstation or PC.

{USERNAME} User Name Inserts the name of the person currently logged into the workstation or PC.

430 Appendix C Keywords for Standard and Custom Forms

Encounter Keywords The following lists the encounter keywords that can be used on the form:

Table 113: Encounter Keywords and Descriptions

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ADMDATE} Admission Date Inserts the encounter Admission Date. If no Admission Date is available the system leaves this blank.

{ADMDX} Admission Dx Inserts Admission Dx listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx is available.

{AGE} Age Inserts patient's age, if known, using the same format as displayed on the patient information tab. If the patient's age in not available the system leaves this blank.

{ALLCPT + INFO} CPT Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLCPT} CPT Code Description Lists all CPT procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no CPT procedure codes have been listed the system leaves this blank.

{ALLDX + CC} Dx Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code.

{ALLDX + CC + POA} Dx Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flag and POA indicator to the left indicators of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX + POA} Dx Code Description + In addition to the code sequence number, code and POA description, this keyword also lists POA to the right of the diagnosis description.

{ALLDX + POA+SOI+ROM} Dx Code + Description In addition to the code and description, this keyword + SOI + ROM + POA also includes the SOI and the ROM values for the individual code and the POA value. These additional values will appear to the right of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{ALLDX} Dx Code Description Lists all diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

431 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ALLPX + INFO} Px Code Description In addition to the entire sequence number, code and and Modifier + Date code description, this keyword also inserts additional and Surgeon columns to include modifier, procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ALLPX} Px Code Description Lists all procedure codes listed on the encounter Coding tab, including sequence number, code and code description. If no procedure codes have been listed the system leaves this blank.

{ADMDXDESC} Description Inserts Admission Dx Description listed on the Coding tab, if known. The system leaves this blank, if no Admission Dx Description is available.

{ALLRVDX} Reason for Visit Inserts the Reason for Visit sequence number, code sequence number code and/or description. Clintegrity prints all Reason for and description Visits coded, or leaves blank if none have been coded.

{AMLOS} AMLOS Inserts the DRG (primary) AMLOS assigned to the encounter. If AMLOS is not available the system leaves this blank.

{APCINFO} APC, PSI and Payment Inserts three fields to include APC, PSI and Payment Reimbursement Rate. Used with {ALLCPT} type keywords, since APC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{APCRATE} APC Rate Includes the APC Rate for the APC assigned to the HCPCS code. If the APC Rate in not available the system leaves this blank.

{APCREIMBURSEMENT} Total APC Includes the Total calculated APC Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total APC Reimbursement is available the system leaves this blank.

{APGINFO} EAPG, EAPG Type, Inserts four fields per HCPCS code. Used with EAPG Category, and {ALLCPT} type keywords, since EAPG values are code EAPG Rate related and usually display along with corresponding CPT code. This information is only available for outpatient encounters.

{APGRATE} EAPG Rate Includes the EAPG Rate for the EAPG assigned to the HCPCS code. If the EAPG Rate in not available leave it blank.

{APGREIMBURSEMENT} Total EAPG Includes the Total calculated EAPG Reimbursement Reimbursement amount for that encounter. This information is only available for outpatient encounters. If no Total EAPG Reimbursement is available the system leaves this blank.

432 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{ASCINFO} ASC Group and ASC Inserts two fields to include ASC Group and ASC Fee. Fee Used with {ALLCPT} type keywords, since ASC values are code related and usually display along with corresponding CPT code. This information is only available for outpatient encounters

{ASCPAYMENT} ASC Payment This keyword includes the ASC Group Rate for the ASC assigned to the HCPCS code. If the ASC Rate in not available the system leaves this blank.

{ASCREIMBURSEMENT} ASC Reimbursement The keyword includes the Total calculated ASC Reimbursement amount for that encounter. This information is only available for inpatient and outpatient encounters. If no Total ASC Reimbursement is available the system leaves this blank.

{ATTENDPROV} Attending Provider Inserts the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{BILLINFO} Units + Dx Link and This single keyword inserts the number Units, Dx Link Fees and Fees associated with a CPT Code. If any of the information is not available the system leaves this blank.

{CODERID} Coder ID Inserts the coder ID for the encounter.

{CODINGSTATUS} Coding Status Inserts the coding status for that encounter. This will never be blank.

{DISCHDATE} Discharge Date Inserts the encounter Discharge Date. If no Discharge Date is available the system leaves this blank.

{DISCHSTATUS} Discharge Status Inserts the discharge status code and discharge status description. If no discharge status is available the system leaves this blank.

{DRG + DRGDESC} Final DRG and its Inserts the primary Final DRG code and DRG Description descriptions assigned to the encounter.

{DRG} Final DRG Inserts the primary Final DRG code assigned to the encounter.

{DRGREIMBURSEMENT} Final Reimbursement The keyword includes the primary Final DRG reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{DRG_ROM} ROM for the encounter The encounter level ROM value. This value can be added to other keywords to add encounter level ROM to a specific line. For example, {DRG + Description} + {DRG_ROM} prints the DRG number, the DRG Description and the encounter level ROM.

433 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{DRG_SOI} SOI for the encounter The encounter level SOI value. This value can be added to other keywords to add encounter level SOI to a specific line. For example, {DRG + Description} + {DRG_SOI} prints the DRG number, DRG Description and the encounter level SOI.

{GMLOS} Final GMLOS Inserts the Final DRG (primary) GMLOS assigned to the encounter. If GMLOS is not available the system leaves this blank.

{INITIAL_DRG + Initial DRG and its Inserts the primary Initial DRG code and DRG DRGDESC} Description descriptions assigned to the encounter.

{INITIAL_DRG} Initial DRG Inserts the primary Initial DRG code assigned to the encounter.

{INITIAL_DRGREIMBURSE Initial Reimbursement The keyword includes the primary Initial DRG MENT} reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement information is not available the keyword on the form displays as blank.

{INITIAL_GMLOS} Initial GMLOS Inserts the Initial DRG (primary) GMLOS assigned to the encounter. If no GMLOS is available the keyword on the form displays as blank.

{INITIAL_MDC} Initial MDC Inserts the Initial DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the keyword on the form displays as blank.

{LOS} LOS Inserts the LOS listed on the encounter. If no LOS is available the system leaves this blank.

{MDC} Final MDC Inserts the Final DRG (primary) MDC assigned to the encounter. If the DRG MDC is not available the system leaves this blank.

{NOTE} Note This keyword plus the user-defined note ID inserts the custom note into the form. For example, if the user created a user-defined note type labeled Consultant and wanted this note type to be listed on custom form, the user would using the following keyword format {NOTE: Consultant}. If the specified note is not available the system leaves this blank.

{PATACCNT} Patient Account # Inserts the account number as displayed on the Patient tab of the Encounter Information section.

{PATDOB} Patient DOB Inserts the patient’s date of birth (as seen on the Patient window) if known. If the date of birth in not available the system leaves this blank.

{PATMRN} Patient MRN Prints the patient’s medical record number, if known. If the medical record number is not available the system leaves this blank.

434 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PATNAME} Patient Name Inserts the patient’s name. Lastname,firstname,middleinitial.

{PATTYPE} Patient Type Inserts Patient Type using the same format as displayed in the patient banner. For Patient Type the form prints I for patient type Inpatient, O for patient type Outpatient and P for patient type Physician.

{PDX} PDx Code Inserts the PDx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PDx is available.

{PDXDESC} Description Inserts the PDx diagnosis description from the Coding tab column in position 1, if known. If no PDx diagnosis code is listed the system leaves this blank.

{PHYSICIANE&M} Physician E/M Code Includes the Physician E&M code entered into a Physician encounter. If no Physician E&M code is available the system leaves this blank.

{PPX} PPx Code Inserts the PPx diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PPx is available.

{PPXDESC} Description Inserts the PPx diagnosis description from the Coding tab column in position 1, if known. If no PPx diagnosis code is listed the system leaves this blank.

{PRIMPAYOR} Prim Payor Inserts the primary payor code and primary payor description. If no primary payor is available the system leaves this blank.

{PROVNAME} Physician E/M Code This keyword inserts the Provide Name and prints the provider's FirstName LastName. If Provide Name is not available the system leaves this blank.

{RVDX} Reason for Visit Inserts the Reason for Visit sequence number and sequence number and code. Clintegrity prints the Reason for Visits coded, or code leaves blank if none have been coded.

{SECPAYOR} Sec Payor Inserts the secondary payor code and secondary payor description. If no secondary payor is available the system leaves this blank.

{SEX} Sex Print the patient's sex, if known. If the patient's sex is not available the system leaves this blank.

{VISITTYPE} Visit Type Inserts Visit Type (as seen of Patient Info tab) if known. If the Visit Type in not available the system leaves this blank.

{VISITTYPEDESC} Visit Type Description Inserts Visit Type Description, if known. If the Visit Type Description in not available the system leaves this blank.

435 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{WEIGHT} Weight Inserts DRG (primary) weight assigned to encounter. If the DRG weight is not available the system leaves this blank.

{ALLPCS} PCS Code Description Lists all ICD-10 PCS procedure codes listed on the encounter Coding tab, including sequence number, code, and code description. If no procedure codes have been listed the system leaves this blank.

{ADMCM} Admission CM Code Inserts ICD-10 CM Admission Code listed on Coding Tab, if known. Clintegrity leaves this blank, if no Admission CM is available.

{ALLCM+CC} CM Code Description + In addition to the code sequence number, code and CC flags description, this keyword also inserts the CC flag to left of the diagnosis code (CC, MCC, * and **) to left of the diagnosis code.

{ALLCM+CC+POA} CM Code Description + In addition to the code and description, this keyword CC flags + POA also includes the CC flags (CC, MCC, * and **) and indicators POA indicator to the left of the diagnosis code. If no diagnosis codes have been listed the system leaves this blank.

{ALLPCS+FLAG} PCS Code Description Lists all procedure codes listed on the encounter and procedure code Coding tab, including sequence number, code and code flag description and code flag (OR, NOR, POR or *). If no procedure codes have been listed the system leaves this blank.

{ALLPCS+FLAG+INFO} PCS Code Description In addition to the entire sequence number, code and and Modifier + code description, this keyword also inserts additional PCSProcedure flag + columns to include modifier, procedure code flag (OR, Date and Surgeon NOR, POR or *), procedure date, and surgeon.The surgeon displays the Provider ID and Provider Description. ProviderID Provider first name. If no Principal procedure is listed the system leaves this blank.

{POA+CC+SOI+ROM+ALL POA + CC flags + SOI In addition to the code and description, this keyword CM} + ROM + CM Code and also includes the CC, SOI and ROM values for the Description individual code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{POA+SOI+ROM+ALLCM} POA + SOI + ROM + In addition to the code and description, this keyword CM Code and also includes the SOI and ROM values for the individual Description code and the POA value. These additional values appear to the left of the code and description. If no diagnosis codes have been listed the system leaves this blank.

{PPCS+FLAG} Principal Procedure Inserts the Principal Procedure Code from the Coding Code and the tab column in position 1, if known. The system leaves associated flag this blank if no PPCS is available.

436 Appendix C Keywords for Standard and Custom Forms

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{PPCSDESC+FLAG} Description of the Inserts the Principal PCS code and the coding flag Principal PCS Code description from the coding tab column in position 1, if and associated flag known. If no PPCS diagnosis code is listed the system leaves this blank.

{ALLCM} CM Code Description Lists all ICD-10 CM diagnoses codes listed on the encounter Coding tab, including sequence number, code and code description. If no diagnoses codes have been listed the system leaves this blank.

{ALLCM + POA} CM Code Description + In addition to the ICD-10 CM code sequence number, POA code and description, this keyword also lists POA to the right of the diagnosis description

{ALLPCS + INFO} PCS Code Description In addition to the entire sequence number, ICD-10 PCS + Date and Surgeon code and code description, this keyword also inserts additional columns to include procedure date and surgeon. The surgeon displays the Provider ID and Provider Description. ProviderID Providerfirstname Providerlastname. If the Provide ID and description are not available the system leaves this blank.

{ADMCMDESC} Description Inserts ICD-10 CM Admission CM Description listed on the Coding tab, if known. The system leaves this blank, if no Admission CM Description is available.

{ALLRVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number code number, code and/or description. Clintegrity prints all and description Reason for Visits coded, or leaves blank if none have been coded.

{PCM} PCM Code Inserts the ICD-10 CM principal diagnosis code from the Coding tab column in position 1, if known. The system leaves this blank if no PCM is available.

{PCMDESC} Description Inserts the ICD-10 CM principal diagnosis description from the Coding tab column in position 1, if known. If no PCM diagnosis code is listed the system leaves this blank.

{RVCM} Reason for Visit Inserts the ICD-10 CM Reason for Visit sequence sequence number and number and code. Clintegrity prints the Reason for code Visits coded, or leaves blank if none have been coded.

{AMLOS_10} AMLOS for ICD-10 Inserts the ICD-10 DRG (primary) AMLOS assigned to DRG the encounter. If AMLOS is not available the system leaves this blank.

{DRG+DRGDESC_10} Final ICD-10 DRG and Inserts the primary Final ICD-10 DRG code and DRG its Description descriptions assigned to the encounter

437 Clintegrity Coding/Abstracting User Guide

KEYWORD KEYWORD DESCRIPTION FUNCTIONAL DESCRIPTION

{DRGREIMBURSEMENT_1 Final Reimbursement Includes the primary Final DRG for the ICD-10 grouper 0} for ICD-10 grouper reimbursement amount. This information is only available on inpatient encounters and those outpatient encounters where the DRG is being calculated. If the DRG reimbursement is not available the system leaves this blank.

{GMLOS_10} Final GMLOS for Inserts the Final ICD-10 DRG (primary) GMLOS ICD-10 DRG assigned to the encounter. If GMLOS is not available the system leaves this blank.

{MDC_10} Final MDC for ICD-10 Inserts the Final ICD-10 DRG (primary) MDC assigned DRG to the encounter. If the DRG MDC is not available the system leaves this blank.

{WEIGHT_10} Weight for the ICD-10 Inserts ICD-10 DRG (primary) weight assigned to DRG encounter. If the DRG weight is not available the system leaves this blank.

{DRG_10_SOI} SOI value for ICD-10 Inserts the SOI value for the APR DRG assigned to the DRG encounter.

{DRG_10_ROM} ROM value for ICD-10 Inserts the ROM value for the APR DRG assigned to DRG the encounter.

438 Appendix D Synonyms

Appendix D  Synonyms

Standard Synonyms This appendix contains tables listing all standard synonyms used in the CPT, ICD9 Dx, and ICD9 Px Indexes. The synonyms for each book are listed separately:

 CPT Procedures Index (see page 439)

 ICD-9 Diagnosis Index (see page 444)

 ICD-9 CM External Cause Index (see page 452)

 ICD-9 Procedures Index (see page 453)

 ICD-10 CM Index (see page 458)

 ICD-10 PCS Index (see page 468)

If you need more synonyms than provided in the standard Clintegrity set, your System Administrator can create custom synonyms using the System Administrator application. The System Administrator application also enables you to create custom tabular synonyms. For information about using synonyms, see Create or Change Synonyms on page 73.

CPT Procedures Index

Table 114: CPT Procedures Index and Synonyms

CPT TERM OR CODE SYNONYM

acid fast bacilli culture afb

activities of daily living adl

adenosine diphosphate adp

adenosine monophosphate amp

adrenocorticotropic hormone acth

allergen immunotherapy fast

aminolevulinic acid ala

angiotensin converting enzyme ace

antinuclear antibodies ana

barium, enema be

439 Clintegrity Coding/Abstracting User Guide

CPT TERM OR CODE SYNONYM

bethesda system tbs

blood urea nitrogen bun

cardiac magnetic resonance imaging cmri

cerebrospinal fluid csf

cholangiopancreatography ercp

clotting factor ahg

complete blood count cbc

continuous negative pressure breathing cnpb

continuous positive airway pressure cpap

coronary artery bypass graft cabg

corticotropic releasing hormone crh

cystometrogram cmg

cytomegalovirus cmv

cytotoxic screen pra

defibrillator aicd

dehydroepiandrosterone dhea

dihydrotestosterone dht

drug assay inh

dual energy x-ray absorptiometry dxa

electrocardiogram ecg

electrocardiogram ekg

electroencephalography eeg

electromyography emg

electrooculography eog

emission computerized tomography ect

end stage renal disease services esrd

evaluation and management em

extracorporeal membrane oxygenation ecmo

fibrin degradation products fdp

440 Appendix D Synonyms

CPT TERM OR CODE SYNONYM fibrin degradation products ppp fine needle aspiration fna growth hormone, human hgh guanosine monophosphate gmp gabepentin assay gsp hepatitis A vaccine hav hepatitis B vaccine hbv homovanillic acid hva human papilloma virus vaccination hpv hydroxyindoleacetic acid hiaa in vitro fertilization gift in vitro fertilization ivf intermittent positive pressure breathing ippb intrauterine device iud intravenous infusion iv isocitric dehydrogenase, blood idh lactic dehydrogenase ldh lactogen, human placental hpl leucine aminopeptidase lap leukocyte histamine release test lhr lipoprotein hdl lipoprotein, blood vldl luteinizing hormone lh luteinizing releasing factor lrh lymphocyte culture plc lysergic acid diethylamide lsd magnetic resonance angiography mra magnetic resonance imaging mri

441 Clintegrity Coding/Abstracting User Guide

CPT TERM OR CODE SYNONYM

measles and rubella vaccination / 90708 mr

measles, mumps, rubella and varicella vaccination / 90710 mmrv

measles vaccination / 90705 mea

minimum inhibitory concentration mic

multiple sleep latency testing mslt

neurostimulation application tens

nitroblue tetrazolium dye test ntd

partial ossicular replacement porp

percutaneous transluminal angioplasty pta

percutaneous transluminal coronary angioplasty ptca

phencyclidine pcp

phenylalanine pku

photochemotherapy puva

polysomnography psg

positron emission tomography pet

prostate specific antigen psa

red blood cell rbc

sex hormone binding globulin shbg

syphilis test art

syphilis test rpr

syphilis test sts

temporomandibular joint tmj

thyroid stimulating hormone tsh

thyrotropin releasing hormone lats

thyrotropin releasing hormone trh

thyroxine binding globulin tbg

thyroxine, true tt-4

tissue, examination for fungi koh

transurethral microwave thermotherapy destruction of tumt prostate / 53850

442 Appendix D Synonyms

CPT TERM OR CODE SYNONYM transurethral needle ablation of prostate / 53852 tuna transurethral resection of prostate turp triiodothyronine, true tt-3 urethra pressure profile upp uroflowmetry ufr vaporization laser ablation of prostate / 52647 vlap vasoactive intestinal peptide vip voiding pressure studies vp white blood cell wbc

443 Clintegrity Coding/Abstracting User Guide

ICD-9 Diagnosis Index

Table 115: ICD-9 Diagnosis Index and Synonyms

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

abdominal aortic aneurysm aaa

abortion ab

abortion legal tab

acute brain syndrome abs

acute cerebrovascular disease acvd

acute granulocytic leukemia agl

acute hemorrhagic pancreatitis ahp

acute laryngotracheobronchitis altb

acute lymphocytic leukemia all

acute myelogenous leukemia aml

acute necrotizing ulcerative gingivitis anug

acute otitis media aom

acute renal failure arf

admission adm

adrenocortical insufficiency aci

adult respiratory distress syndrome ards

alcohol alc

alcohol abuse non-dependent etoh

amyotrophic lateral sclerosis als

aortic arch syndrome aas

aortic insufficiency ai

aortic stenosis as

appendicitis ap

arteriosclerotic cardiovascular disease ascvd

arteriosclerotic heart disease ashd

arteriovenous av

arteriovenous fistula avf

444 Appendix D Synonyms

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM arteriovenous malformation avm arterioventricular block avb atrial fibrillation af atrial fibrillation (paroxysmal) paf attention deficit disorder add attention deficit disorder with hyperactivity adhd bacterial endocarditis abe bacterial endocarditis be bilateral bundle branch block bbbb bladder neck contracture bnc bladder neck obstruction bno bleeding uterus aub block bundle (branch) bbb block bundle left (branch) bbb block bundle right (branch) rbbb brain syndrome (organic) obs bronchiolitis obliterans with organizing pneumonia boop bronchitis ltb carpal tunnel syndrome cts cerebrovascular accident cva cesarean section cs chronic active hepatitis ach chronic coronary insufficiency cci chronic glomerulonephritis cgn chronic granulocytic leukemia cgl chronic lymphocytic leukemia cll chronic obstructive pulmonary (lung) disease copd chronic pelvic inflammatory disease cpid

445 Clintegrity Coding/Abstracting User Guide

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

chronic renal failure crf

chronic ulcerative colitis cuc

clostridium difficile / 008.45 cdif

completely normal delivery svd

conduction defect (heart) ivcd

congestive heart failure chf

coronary artery disease cad

Creutzfeldt Jakob disease cjs

crystalline keratitis ick

cystic fibrosis cf

decreased fetal movement dfm

deep vein thrombosis dvt

defect,atrial septal asd

delayed gastric emptying dge

delirium tremens dt

delivery complicated by cephalopelvic disproportion cpd

diabetes dm

diabetes (adult onset) aodm

diabetes (insulin dependent) iddm

diabetic ketoacidosis dka

disease dz

displacement intervertebral disc hnp

disseminated intravascular coagulopathy dic

disseminated mycobacterium avium intracellular complex / dmac 031.2

Down’s disease or syndrome ds

dysfunctional uterine bleeding dub

dyspnea pnd

end stage renal disease esrd

eosinophilia myalgia syndrome ems

446 Appendix D Synonyms

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

Epstein-Barr virus infection ebv

Escherichia coli infection ecoli failure left ventricle (heart) lhf failure right heart rhf failure to thrive ftt family history fh fatty liver disease fld female genital mutilation status / 629.2 fgm fetopelvic disproportion fpd fever of unknown origin fuo fibromuscular dysplasia fmd follow-up fu foreign body fb fracture fx functional uterine bleeding fub gastric outlet obstruction goo gastroesophageal laceration-hemorrhage syndrome ge gastroesophageal reflux gerd gastrointestinal gi gastrointestinal stromal tumor gist giant cell arteritis gca glioblastoma multiforme gbm gonorrhea gc graft versus host disease gvhd

Guillain-Barre disease gbs hairy cell leukemia hcl helicobacter pylori / 041.86 hpyl hemolytic disease of newborn hdn

447 Clintegrity Coding/Abstracting User Guide

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

hepatic encephalopathy he

hepatitis, viral, type A hepa

hepatitis, viral, type B hepb

hepatitis, viral, type C hepc

hepatitis, viral, type D hepd

hepatitis, viral, type E hepe

hereditary hemolytic anemia hha

high blood pressure hbp

hip dysplasia (congenital) cdh

histiocytic lymphoma dhl

history hx

history of ho

history of cerebrovascular accident without residual deficits hx cva

history of malignant neoplasm hxca

Hodgkin’s disease nodular sclerosis hdns

Hodgkin’s disease nodular sclerosis nshd

Hodgkin’s lymphoma hl

human immunodeficiency virus hiv

hyaline membrane disease hmd

hyperparathyroidism hpt

hypertension (table) htn

hypertensive cardiovascular disease hcvd

hypertensive heart disease hcd

hypertensive heart disease hhd

hypertrophic subaortic stenosis (idiopathic) ihss

idiopathic thrombocytopenia purpura itp

interstitial keratitis ik

intrauterine contraceptive device iud

iron deficiency anemia ida

448 Appendix D Synonyms

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM irritable bowel syndrome ibs juvenile rheumatoid arthritis jra juvenile xanthoganuloma / 216 jxg knee derangement (internal) idk laceration lac large for dates lga low back pain lbp lupus erythematosus le mitral stenosis mvs mitral valve prolapse mvp mixed nodular lymphoma nml multifocal motor neuropathy / 357.89 mmn multinodular goiter mng multiple sclerosis ms mycobacterium avium intracellulare complex bacteremia / mac 031.2 myocardial Infarct ami myocardial Infarct mi narrow angle glaucoma nag nausea with vomiting nv necrotizing enteritis of fetus or newborn nne

Neoplasm Table ca nephrosis ins neuroleptic malignant syndrome nms newborn nb nonsuppurative otitis media nom normal delivery nsvd obstruction intestine bo obstruction intestine sbo

449 Clintegrity Coding/Abstracting User Guide

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

open angle glaucoma oag

organic anxiety syndrome oas

orthostatic hypotension ioh

osteoarthritis oa

osteoarthrosis (degenerative joint disease) djd

otitis externa oe

otitis media om

paroxysmal atrial tachycardia pat

paroxysmal ventricular tachycardia pvt

partial anomalous pulmonary venous connection papvc

patent ductus arteriosus pda

pelvic inflammatory disease pid

peripheral arterial disease pad

peripheral artery embolism paod

peripheral vascular disease pvd

peptic ulcer pud

phenylketonuria pku

polycystic kidney disease pkd

polycystic renal disease prd

postmenopausal bleeding pmb

postoperative po

posttraumatic stress disorder ptsd

premature atrial contraction apc

premature atrial contraction pac

premature rupture membranes prm

premature rupture membranes prom

premature ventricular contractions pvc

premenstrual syndrome pms

premenstrual tension pmt

450 Appendix D Synonyms

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM prostate hypertrophy bph pulmonary hypertension pah pulseless electrical activity / 427.5 pea respiratory distress syndrome (newborn) rds respiratory syncytial virus rsv rheumatic heart disease rhd rheumatoid arthritis ra serous otitis media som shaken infant syndrome sis shortness of breath sob sickle cell crisis scc sick sinus syndrome sss small for gestational age (fetus or newborn) sga status post sp streptococcal infection Group A strepa streptococcal infection Group B strepb streptococcal infection Group C strepc streptococcal infection Group D strepd streptococcal infection Group G strepg subacute bacterial endocarditis sbe subdural brain hematoma sdh sudden infant death syndrome sids superior vena cava syndrome svcs supraventricular tachycardia svt sympathetic reflex dystrophy rsd syndrome of inappropriate secretion of antidiuretic siadh hormone systemic lupus erythematosus sle

Table of Drugs and Chemicals tabl temporomandibular joint-pain-dysfunction syndrome tmjd

451 Clintegrity Coding/Abstracting User Guide

ICD-9 DIAGNOSIS TERM OR CODE SYNONYM

temporomandibular joint-pain-dysfunction syndrome tmjs

thoracic outlet syndrome tos

thrombocytopenia due to drugs dit

thrombocytopenic thrombotic purpura ttp

torn medial meniscus (current injury) tmm

total anomalous pulmonary venous return tapvr

toxic shock syndrome tss

transient ischemic attack tia

transient tachypnea (of newborn) ttn

tuberculosis tb

tumor lysis syndrome tls

upper respiratory infection uri

urinary retention ur

urinary stress incontinence usi

urinary (tract) infection uti

varicose vein vv

ventricular septal defect vsd

ventricular tachycardia vt

wet lung syndrome wls

Wolff-Parkinson-White syndrome wpw

ICD-9 CM External Cause Index

Table 116: ICD-9 CM External Cause Index and Synonyms

ICD-9 EXTERNAL CAUSE TERM OR CODE SYNONYM

accident occurring at aoa

activity status ecs

motor vehicle accident mva

452 Appendix D Synonyms

ICD-9 Procedures Index

Table 117: ICD-9 Procedures Index and Synonyms

ICD-9 PROCEDURE TERM OR CODE SYNONYM

above-knee amputation aka

adenoidectomy with tonsillectomy ta

angiocardiography acg

aortic valve replacement avr

aortocoronary bypass cabg

aortofemoral vascular bypass afbg

appendectomy appy

arterial blood gas measurement abg

arteriovenostomy av

artificial rupture of membranes arom

autologous bone marrow transplant abmt

basal metabolic rate bmr

below-knee amputation bka

bilateral salpingo-oophorectomy bso

bile duct exploration bde

bi-level positive airway pressure assisted ventilation bipap

biopsy bx

biopsy bone marrow bmb

bundle of his study hbe

cardioverter/defibrillator implant aicd

cardioverter/defibrillator implant icd

carpal tunnel release ctr

cataract extraction extracapsular approach ecce

catheterization cath

catheterization artery uac

catheterization umbilical vein uvc

CAT scan cat

453 Clintegrity Coding/Abstracting User Guide

ICD-9 PROCEDURE TERM OR CODE SYNONYM

CAT scan ct

central venous pressure measurement cvp

cesarean section cs

intervertebral chemonucleolysis / 80.52 cnl

chest radiography cxr

common bile duct exploration cde

continuous positive airway pressure assisted ventilation cpap

cystometrogram cmg

cystourethrogram cu

dacryocystorhinostomy dcr

dilation and curettage dc

electrocardiogram ecg

electrocardiogram ekg

electroencephalogram eeg

electromyogram emg

electroretinogram erg

electroshock therapy est

endoscopic retrograde cholangiography ercp

esophagogastroduodenoscopy egd

fallopian tube ligation btl

fetal electrocardiogram fecg

femoropopliteal vascular bypass fpb

full thickness skin graft ftsg

implantation of cardiac synchronization defibrillator / 00.51 crtd

implantation of cardiac synchronization pacemaker / 00.50 crtp

incision id

injection thrombolytic tpa

insertion contraceptive device (intrauterine) iud

insertion of vertical expandable prosthetic titanium rib device veptr / 78.41

454 Appendix D Synonyms

ICD-9 PROCEDURE TERM OR CODE SYNONYM insertion of vascular access device vad insertion or replacement of external ventricular drain / 02.21 evd intermittent positive pressure breathing ippb internal mammary coronary artery bypass lima internal mammary coronary artery bypass rima intracardiac echocardiography ice intraoperative cholangiogram ioc kidney-ureter-bladder radiography kub knee replacement tkr laparoscopic assisted vaginal hysterectomy lavh left heart catheterization lhc left salpingectomy oophorectomy lso low cervical cesarean section lccs low forceps delivery lfd

Marshall Marchetti Krantz operation mmk mechanical ventilation imv mitral valve replacement mvr modified radical mastectomy mrm multiple sleep latency test mslt negative pressure assisted ventilation cnp nephrectomy nx occupational therapy ot open reduction with internal fixation of fracture orif penetrating keratoplasty pk percutaneous endoscopic gastrostomy peg percutaneous endoscopic gastrojejunostomy pegjj percutaneous endoscopic jejunostomy pej percutaneous transluminal angioplasty pta percutaneous transluminal coronary angioplasty ptca

455 Clintegrity Coding/Abstracting User Guide

ICD-9 PROCEDURE TERM OR CODE SYNONYM

peripheral parenteral infusion concentrated nutrition ppn substance

physical therapy pt

positive end expiratory pressure assisted mechanical peep ventilation

pressure support assisted mechanical ventilation psv

pyelogram ivp

radioisotope scan PET

removal foreign body fb

reduction fracture fx

right heart catheterization rhc

right salpingectomy oophorectomy rso

salpingo-oophorectomy so

skin graft stsg

speech therapy st

submucous resection smr

thoracoabdominal aneurysmectomy with graft to aorta taaa

tonsillectomy with adenoidectomy ta

total abdominal hysterectomy / 68.49 tah

total hip replacement thr

total laparoscopic hysterectomy / 68.41 tlh

total parenteral nutrition tpn

transcutaneous nerve stimulation tens

transjugular intrahepatic portosystemic shunt tips

transmetatarsal amputation tma

transurethral resection tur

transurethral bladder resection turb

transurethral prostatectomy by ultrasound guided laser tulip

transurethral prostate resection turp

transverse abdominus myocutaneous breast reconstruction tram

456 Appendix D Synonyms

ICD-9 PROCEDURE TERM OR CODE SYNONYM ultrasonography sonogram ultrasonography us upper digestive radiography ugi vectocardiogram vcg

457 Clintegrity Coding/Abstracting User Guide

ICD-10 CM Index

Table 118: ICD-10 CM Index and Synonyms

ICD-10 CM TERM OR CODE SYNONYM

abdominal aorta aneurysm aaa

abortion (complete) (spontaneous) ab

acquired immune deficiency syndrome aids

active chronic hepatitis ach

acute brain syndrome abs

acute cerebrovascular disease acvd

acute hemolytic transfusion reaction ahtr

acute kidney failure akf

acute necrotizing ulcerative gingivitis anug

acute renal failure arf

acute idiopathic pulmonary hemorrhage in infants aiphi

acute hemorrhagic pancreatitis ahp

acute otitis media aom

adrenocortical insufficiency aci

acute respiratory distress syndrome/J80 ards

aids-related complex arc

alcohol abuse etoh

angle-closure glaucoma nag

aortic arch syndrome aas

aortic insufficiency ai

aortic stenosis as

apparent life threatening event in infant and newborn alte

arteriosclerotic cardiovascular disease ascvd

arteriosclerotic heart disease ashd

arteriovenous fistula avf

arteriovenous malformation avm

arthritis,rheumatoid ra

458 Appendix D Synonyms

ICD-10 CM TERM OR CODE SYNONYM atrial fibrillation af atrial premature contractions apc atrial septal defect asd atrioventricular block avb atrioventricular nodal re-entrant tachycardia avnrt atrioventricular nodal re-entrant tachycardia avrt attention deficit disorder add attention deficit disorder with hyperactivity adhd atypical squamous cells cannot exclude high grade asc-h squamous intraepithelial lesion on cytologic smear atypical squamous cells of undetermined significance on asc-us cytologic smear bilateral bundle branch block bbbb bladder neck contraction bnc bladder neck obstruction bno bleeding,uterus aub block bundle (branch) bbb block,bundle branch bbb block, bundle branch, left / 144.7 lbbb body mass index bmi bronchiolitis obliterans organized pneumonia boop cerebrovascular accident cva cesarean delivery cs chronic coronary insufficiency cci chronic glomerulonephritis cgn chronic kidney disease ckd chronic obstructive pulmonary disease copd chronic pelvic inflammatory disease cpid chronic renal failure crf completely normal delivery / O80 svd

459 Clintegrity Coding/Abstracting User Guide

ICD-10 CM TERM OR CODE SYNONYM

complications, surgical procedure po

conduction defect ivcd

chronic ulcerative colitis cuc

congestive heart failure chf

coronary artery disease cad

Creutzfeldt Jakob disease cjs

crib death syndrome sids

cystic fibrosis cf

deep vein thrombosis dvt

delayed gastric emptying dge

delayed hemolytic transfusion reaction dhtr

delayed serologic transfusion reaction dstr

delirium tremens dt

delivery complicated by fetopelvic disproportion cpd

diabetes dm

diffuse idiopathic skeletal hyperostosis dish

dihydropyrimidine dehydrogenase deficiency dpd

Disease (as main term) dz

displacement intervertebral disc hnp

disseminated mycobacterium avium intracellulare dmac complex

do not resuscitate dnr

down syndrome ds

dysfunctional uterus bleeding dub

dyspnea pnd

end stage renal disease / N18.6 esrd

eosinophilia-myalgia syndrome ems

Epstein-Barr virus infection ebv

Escherichia coli infection ecoli

examination follow up fu

460 Appendix D Synonyms

ICD-10 CM TERM OR CODE SYNONYM external cause ex failure descent of head ftd failure to thrive ftt failure, heart, congestive rhf family history fh fatty liver disease fld fever of unknown origin fuo foreign Body fb fracture, traumatic fx functional bleeding uterus fub graft-versus-host disease gvhd graft-versus-host disease goo gastric outlet obstruction gerd gastroesophageal reflux disease gca giant cell arteritis gca gonorrhea gc

Guillain-Barre disease or syndrome gbs hairy cell leukemia hcl hereditary hemolytic anemia hha hemolysis, elevated liver enzymes and low platelet hellp count hemolytic disease (newborn) hdn hepatic encephalopathy he hepatitis, viral, type A hepa hepatitis, viral, type B hepb hepatitis, viral, type C hepc hepatitis, viral, type E hepe high blood pressure hbp

461 Clintegrity Coding/Abstracting User Guide

ICD-10 CM TERM OR CODE SYNONYM

high grade squamous intraepithelial lesion on hgsil cytologic smear

histiocytic lymphoma dhl

history hx

history of malignant neoplasm hxca

Hodgkin’s lymphoma hl

human immunodeficiency virus hiv

hyaline membrane disease hmd

hyperparathyroidism hpt

hypertension htn

hypertension gestational pih

hypertension heart hhd

hypertrophic subaortic stenosis ihss

idiopathic infantile arterial calcification iiac

idiopathic respiratory distress syndrome irds

idiopathic thrombocytopenic purpura itp

immune reconstruction inflammatory syndrome iris

induced abortion tab

infant, liveborn nb

intellectual disability iq

iron deficiency anemia ida

irritable bowel syndrome ibs

interstitial keratitis ik

intestine obstruction sbo

intravascular coagulopathy dic

intrauterine contraceptive device iud

juvenile rheumatoid arthritis jra

462 Appendix D Synonyms

ICD-10 CM TERM OR CODE SYNONYM ketoacidosis dka knee derangement idk large for dates lga left ventricular failure lhf low back pain lbp low grade squamous intraepithelial lesion on lgsil cytologic smear lupus erythematosus le medial meniscus tear tmm methicillin resistant staphylococcus aureus mrsa methicillin susceptible staphylococcus aureus mssa microvillus inclusion disease mvd microvillus inclusion disease mvid mitochondrial myopathy, encephalopathy, lactic melas acidosis and stroke-like episodes syndrome mitral stenosis mvs mitral valve prolapse mvp multinodular goiter mng multiple sclerosis / G35 ms myocardium infarct mi myoclonic epilepsy associated with ragged-red merff fibers nausea with vomiting nv

Neoplasm Table ca nephrosis ins neuropathy, ataxia and retinitis pigmentosa narp syndrome neuroleptic malignant syndrome nms

463 Clintegrity Coding/Abstracting User Guide

ICD-10 CM TERM OR CODE SYNONYM

nonsuppurative otitis media nom

normal delivery / O80 nsvd

open angle glaucoma oag

organic brain syndrome obs

orthostatic hypotension ioh

osteoarthritis oa

osteoarthritis djd

otitis externa oe

otitis media om

paroxysmal atrial fibrillation paf

paroxysmal ventricular tachycardia pvt

partial anomalous pulmonary venous connection papvc

patent ductus arteriosus pda

pelvic inflammatory disease pid

peptic ulcer pud

peripheral arterial disease pad

peripheral artery embolism paod

peripheral vascular disease pvd

personal history ho

phenylketonuria pku

polycystic kidney disease pkd

polycystic renal disease prd

postmenopausal bleeding pmb

posterior reversible encephalopathy syndrome pres

post-traumatic stress disorder ptsd

decreased fetal movement dfm

464 Appendix D Synonyms

ICD-10 CM TERM OR CODE SYNONYM pregnancy complicated by fetal growth retardation iugr intrauterine fetal death iufd pregnancy supervision elderly mother ama premature atrial contraction pac premenstrual syndrome pms premenstrual tension pmt premature ventricular contractions pvc pulmonary hypertension pah prolonged reversible ischemic neurologic deficit prind premature rupture of membranes prm premature rupture of membranes prom prostate enlargement / N40.0 bph pyrexia of unknown origin puo respiratory distress syndrome of newborn rds reversible ischemic neurologic deficit rind rheumatic heart disease rhd right bundle branch block rbbb shaken infant syndrome sis short breath sob short lasting unilateral neurologiform headache sunct with conjunctival injection and tearing sickle cell disease with crisis scc sick sinus syndrome / I49.5 sss small for dates sga status sp subacute bacterial endocarditis sbe superior vena cava syndrome svcs

465 Clintegrity Coding/Abstracting User Guide

ICD-10 CM TERM OR CODE SYNONYM

supraventricular tachycardia svt

syndrome, carpal tunnel cts

syndrome of inappropriate secretion of antidiuretic siadh hormone / E22.2

systemic lupus erythematosus sle

Table of Drugs and Chemicals rx

temporomandibular joint pain dysfunction tmjd syndrome

temporomandibular joint pain dysfunction tmjs syndrome

tPA (rtPA) administration in a different facility within tpa the last 24 hours prior to admission to current facility

transient ischemic attack tia

transitory tachypnea of newborn / P22.1 ttn

traumatic brain injury tbi

thrombocytopenia due to drugs dit

thrombocytopenic thrombotic purpura ttp

thoracic outlet syndrome tos

total anomalous pulmonary venous return tapvr

toxic shock syndrome tss

trigeminal autonomic cephalgia tac

tuberculosis tb

tumor lysis syndrome / E88.3 tls

upper respiratory infection uri

urine retention ur

466 Appendix D Synonyms

ICD-10 CM TERM OR CODE SYNONYM urinary stress incontinence usi urinary tract infection uti varix vv ventricular fibrillation vf ventricular septal defect vsd ventricular tachycardia vt wet lung syndrome / P22.1 wls

Wolff-Parkinson-White syndrome / I45.6 wpw

467 Clintegrity Coding/Abstracting User Guide

ICD-10 PCS Index ICD-10 PCS Index and Synonyms

ICD-10 PCS TERM SYNONYM

artificial rupture of membranes arom

aortic valve replacement /02RF avr

basal metabolic rate-see Measurement, bmr physiological systems

bilateral tubal ligation-main term occlusion / 0UL7 btl

blood pressure-see Measurement, arterial bp

biopsy bx

bronchial alveolar lavage bal

cardiopulmonary bypass / 5A1221Z cpb

carpal tunnel release-see Release / 01N5 ctr

central venous pressure-see Measurement, venous cvp

cesarean section / 10D0 cs

chest x-ray -see Plain Radiography / BW03ZZZ cxr

computerized tomography (CT Scan) ct scan

continuous positive airway pressure-see Assistance, cpap respiratory

coronary artery bypass cabg

detachment, leg, lower bka

detachment, leg, upper aka

dilation, artery pta

drainage id

ECMO see Performance, circulatory ecmo

electrocardiogram-see Measurement, cardiac ekg

electroconvulsive therapy / GZB ect

electroencephalogram-see Measurement,central eeg nervous

electromyogram-see Measurement, musculoskeletal emg

electrophysiologic stimulation-see Measurement, eps cardiac

468 Appendix D Synonyms

ICD-10 PCS TERM SYNONYM endoscopic retrograde cholangiopancreatography -- ercp see Fluoroscopy, hepatobiliary system and pancreas esophagogastroduodenoscopy egd dilation and curettage- see Extraction, endometrium dc extraction, marrow bmb extracorporeal shock wave lithotripsy-see eswl Fragmentation removal of foreign body- see Extirpation fb high forceps delivery / 10D07Z5 hfd hip replacement thr

Intra-aortic balloon pump-see Assistance, cardiac iabp

Intermittent mandatory ventilation-see Assistance, imv respiratory intermittent positive pressure breathing-see ippb Assistance, respiratory intraoperative anesthetic effect monitoring and iaemt titration-see Monitoring, central nervous laparoscopic assisted vaginal hysterectomy / lavh 0UT9FZZ left heart catheterization / 4A023N7 lhc low cervical cesarean section / 10D00Z1 lccs low forceps delivery / 10D07Z3 lfd

MR angiography mr mid forceps delivery / 10D07Z4 mfd mitral valve replacement / 02RG mvr percutaneous endoscopic gastrostomy peg percutaneous endoscopic jejunostomy pej peripheral parenteral nutrition - see Introduction, ppn nutritional substance pressure support ventilation-see Performance, psv respiratory percutaneous transluminal coronary angioplasty- see ptca Dilation, heart and great vessels

469 Clintegrity Coding/Abstracting User Guide

ICD-10 PCS TERM SYNONYM

positive end expiratory pressure-see Assistance, peep respiratory

physical therapy / F07 pt

pyelography ivp

right heart catheterization / 4A023N6 rhc

bi-level positive airway pressure assisted bipap ventilation-see Assistance, respiratory

positron emission tomographic (PET) pet scan

speech therapy / F06 st

transbronchial needle aspiration-see Drainage, tbna respiratory system

transurethral microwave thermotherapy of prostate tumt

transurethral needle ablation of prostate tuna

transurethral resection of prostate turp

transverse rectus abdominis myocutaneous flap tram reconstruction

tonsillectomy & adenoidectomy / 0CT ta

total abdominal hysterectomy / 0UT90ZZ tah

ultrasonography us

umbilical vein catheterization / 06H033T uvc

vectorcardiogram-see Measurement, cardiac vcg

visual evoked potential vep

x-ray see Plain radiography, kidney, ureter and kub bladder / BT04

470 Appendix E Search Tips

Appendix E  Search Tips

This appendix provides information about searching in general.

General Search Information

 FTE (full text entry) means a multi-word term entered, without commas.

 When performing a Find All search, Clintegrity considers each character and word, including plurals, hyphens, conjunctions and prepositions (such as by, due, to, for, and with).

 When performing searches for single term, multiple terms and comma delimited, the search engine realizes that plurals, hyphens, conjunctions and prepositions (such as by, due, to, for, and with) might not apply.

 If the term is not in the index, the search engine won’t find it, but that does not mean the term you entered is not a valid medical term.

Types of Searches Clintegrity supports the following types of searches:

 Single-Term Search

 Multiple-Term Search (FTE)

 Comma-Delimited Search

 Find All - Index Search

A way to enter advanced search criteria is also provided (see page 474).

Single-Term Search A Single-Term Search means you are searching for just one word.

 The search engine matches the term letter by letter until an exact match is found.

 If no exact match is found, the search engine eliminates the final letter of the term until a partial match found (or all letters have been eliminated).

When performing searches for a single term, the search engine recognizes that plurals, hyphens, conjunctions and prepositions (such as by, due to, for, and with) might not apply.

471 Clintegrity Coding/Abstracting User Guide

Multiple-Term Search (FTE) A Multiple-Term Search—also known as a Full Text Entry or FTE Search—means you are searching on either a phrase (Chicken Pox) or on a word and its modifiers (compound fracture tibia). That is, you enter multiple terms that are not separated by a comma.

The system uses FTE search logic to find matches, as follows:

 The search engine first tries to match all terms.

 If no exact or partial match is found for all terms, the search engine finds the closest indexed term for each input term, and then try to match all the replaced terms.

 If the search engine cannot match all the replaced input terms, the system discards one term and try all combinations of the remaining terms. If it still cannot find a match, it discards two terms and try all combinations, and so on.

 If the search engine finds an exact match for both the first and second term entered, the first term takes precedence over second term. Similarly, matches on the first word take precedence over matches on subsequent words in a multi-word term. For example, you get different results for deformity flexion than for flexion deformity.

 Non-essential modifiers (such as by, due to, for, and with) are not considered for term matches.

 Words in parentheses are not considered for term matches For example, searching on murmur, pulmonic returns murmur, pulmonic (value); but searching on murmur, value returns the main murmur entry.

 Multiple term matches take precedence over single term matches.

 Full term matches take precedence over partial term matches.

 Terms in the possessive (such as Bell’s palsy and Addison’s disease) can be entered with or without the apostrophe (Bell palsy, Bells palsy, or Bell’s palsy).

Tips for FTE Searching When entering your search text, keep in mind the following guidelines to ensure a successful result:

 Enter more than one or two characters. For example, Comp is closer to your target than Co.

 Drop the last few characters if you are not sure the term is in the index, or if your first search didn’t return the expected result:

 Autotransplant instead of Autotransplantation

 prophylac instead of prophylactic

 Deficien instead of Deficiency or deficient

 Be as precise as possible. For example, to search for the item 264.1, whose full term is Vitamin A Deficiency w Xerosis/Bitot's Spot, you can type any of these:

 Vitamin A deficiency with xerosis conjunctival with Bitot's spot  Vitamin A xerosis Bitot  Deficiency vitamin A with xerosis However, if you enter just Deficiency A with xerosis, only Deficiency is found.

472 Appendix E Search Tips

Comma-Delimited Search In a Comma-Delimited Search, you enter terms separated by commas. You are searching for items that match all the terms.

 Comma-delimited searching does not apply FTE logic.

 If the search engine is unable to find exact match for the main term, it identifies the closest match to the main term, and then attempts to find the subterm match under that main term.

 When performing comma-delimited searches, the search engine recognizes that plurals, hyphens, conjunctions, and prepositions (such as by, due, to, for, and with) might not apply.

Tips for Comma-Delimited Searching

 Terms must be separated by commas but without spaces after the commas. For example, enter aberration,mental not aberration, mental.

 Enter the exact word to avoid matching the wrong term (especially for the main term): For example, Code 300.9: Aberration,mental. If entered as Aberratio,mental or Aberrati,mental, the system stops at Aberratio.

 The search engine does not make up any sub-term (except non essential modifiers). For example, if you are looking for 264.1: Vitamin A Deficiency with Xerosis/Bitot's Spot, you need to enter: Deficiency,vitamin,A,with Bitot's spot If any of the essential terms are missing, the search not locate 264.1. For example if vitamin is left out, the search finds only deficiency.

Find All - Index Search A Find All -Index Search looks for the main term, subterms, and non-essential modifiers for term matches.

 When performing a Find All - Index Search, Clintegrity considers each character and word, including plurals, hyphens, conjunctions and prepositions (such as by, due, to, for, and with).

 It performs both multiple- and single-term searches.

 It does not apply FTE logic.

 The search engine uses word by word matching, meaning it skips the main term or any sub-terms. Even if the search phrase—e.g, vitamin, A, xerosis, conjunctiv, with Bitot's spot— is missing the main term—e.g., Deficiency—the search engine still locates Deficiency deficient vitamin (multiple) NEC A with xerosis conjunctival with Bitot's spot; vitamin A deficiency which hyper links to E50.1, Vitamin A deficiency with Bitot's spot and conjunctival xerosis in the Tabular List.

473 Clintegrity Coding/Abstracting User Guide

Advanced Search Criteria for Selection Rules This section explains setting criteria for selection rules. (See also Setting Compliance Rules.)

While setting up rule condition criteria for advanced searches:

 Add (or remove) lines by clicking the Add (or Remove) link.

 Narrow your search by entering multiple lines of search criteria. For example, to find all encounters for Blue Cross for last February, you need one line to find the payor Blue Cross and another line to find the date of February.

 Look up a code by clicking the magnifying glass icon to access the Code Lookup screen.

 Enter dates in the format mm/dd/yyyy.

Setting Rule Condition Criteria

Select In Condition Value CustomOperator

Left Bracket Right Bracket

Figure 294: Setting Rule Condition Criteria Screen

 Notice there are six columns – leftBracket, Select In, Condition, Value, rightBracket, and CustomOperator.

 The Select In option is categories or individuals, such as Admit Date, CM - Any, PCS - Primary, or Provider.

 The Value option is the criteria you are setting for that field, such as a specific date or a name.

 The leftBracket and rightBracket options are used to start and end bundled lines respectively.

 The CustomOperator option enables you to select either the And or an Or option while displaying a new line for rule conditions.

 Notice that you can add (or remove) lines, by clicking the Add (or Remove) link. You can narrow your search by entering multiple lines of search criteria. For example, to find all encounters for Blue Cross for last February, you need one line to find the payor Blue Cross and another line to find the date of February.

 By selecting the appropriate operator, you limit the number of encounters selected:

o Equal T – The Select In equals the Value you set. For example, select Coder as the Select In, select equal to as the Condition, and enter jsmith as the Value, to find all encounters coded by JSmith.

474 Appendix E Search Tips

 Not Equal To – The Select In does not equal the Value. For example, select Facility as the Select In, not equal to as the Condition and enter County General as the Value, to search for encounters that are not for the County General facility.

 Greater Than – The Select In is greater than the Value. For example, select DRG as the Select In, greater than as the Condition and enter 674 as the Value to find all encounters that have been assigned DRG 675, 676, and all other DRGs higher than 674.

 Less Than – The Select In is less than the Value. For example, select Total Charges as the Select In, less than as the Condition and enter 100.00 as the Value to find all encounters that have total charges value of less than $100.00.

 In List – You specify a particular list as the Value. For example, select MRN as the Select In, in list as the Condition and enter 67863, 80473, 65430, 19786 in the text field to find any encounters that have any of those particular MRNs. (Notice that the list does not have to be numerically or alphabetically sequential.)

 Not In List – You specify as the Value a list of items you don’t want found. For example, select Payor as the Select In, not in list as the Condition and enter Medicare, Blue Shield, Cigna as the Value to find any encounters that are for Payors other than those three payors.  Between – The Value of the Select In falls between two values, separated by a dash. For example, select Admit Date as the Select In, between in the Condition and enter 01/01/2001-01/31/2001 as the Value to find all encounters that have an admit date between January 1 and January 31, 2001. Notice that dates are entered in the format MM/DD/YYYY. (Notice that the list must be numerically or alphabetically sequential.)

Example A Suppose you want to select encounters that:

 Include Dx code 10000 but not claims that are part of DRG 545.

 Have an admit date after 01/01/2007 but before 06/01/2007

To construct the search criteria:

1. Select for the DX code 1000 as follows:

a. Choose Diagnosis-Any from the Field list.

b. Choose equal to from the Operator list.

c. Enter 10000 in the Value field. d. Click Add to add another line.

2. Exclude claims that are part of DRG 545 as follows:

a. Choose DRG from the Field list.

b. Choose not equal to from the Operator list.

c. Enter 545 in the Value field. d. Click Add to add another line.

475 Clintegrity Coding/Abstracting User Guide

3. Define the start of the date range as follows:

a. Choose Admit Date from the Field list.

b. Choose Greater Than from the Operator list.

c. Enter 01/01/2007 in the Value field. d. Click Add to add another line.

4. Define the end of the data range as follows:

a. Choose Admit Date from the Field list.

b. Choose less than from the Operator list.

c. Enter 06/01/2007 in the Value field.

Example B Suppose you want to select encounters that:

 Include (CM Principal code 125.10 and also includes CM Secondary code 150.9).

To construct the search criteria:

1. Select for the (CM Principal code 125.10 as follows:

a. Choose (from the leftBracket list.

b. Choose CM Principal from the Select In list.

c. Choose equal to from the Condition list.

d. Enter 125.10 in the Value field. e. Choose from the rightBracket list.

f. Click And to add another line.

2. Select for the CM Secondary code 150.9) as follows:

a. Choose from the leftBracket list.

b. Choose CM Secondary from the Select In list.

c. Choose equal to from the Condition list.

d. Enter 150.9 in the Value field. e. Choose) from the rightBracket list.

476 Appendix E Search Tips

Example C You want to select encounters where the coder is Daphne, Velma, Buffy, Jean, or Marie. To construct that criteria:

1. Choose Coder from the Field list.

2. Choose In List from the Operator list.

3. Enter the following in the Value field: Daphne, Velma, Buffy, Jean, Marie

477 Clintegrity Coding/Abstracting User Guide

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478 Appendix F Comparison of Edits

Appendix F  Comparison of Edits

The tables in this appendix compare Coding and Compliance edits, so you can see which edits are duplicated in both products, which assists you in deciding where the edits should trigger. The tables are:

 Regulatory

 Data Quality Edits

 Revenue Edits

 Custom Rules

In the tables, the following designations are used:

 X – Edit used.

 V – Edit used for validation.

 S – Edit used for selection.

Coding’s rules for Inpatient, Outpatient and Physician encounters are set up under Coding/Abstracting\Setup:

 IP Rule Settings (Complete Encounters), IP Rule Settings ICD-10 (Complete Encounters), IP Rule Settings (Incomplete Encounters), and IP Rule Settings ICD-10 (Incomplete Encounters)

 OP Rule Settings (Complete Encounters), OP Rule Settings ICD-10 (Complete Encounters), OP Rule Settings (Incomplete Encounters), OP Rule Settings ICD-10 (Incomplete Encounters)

 Physician Rule Settings (Complete Encounters) and Physical Rule Settings (Incomplete Encounters)

Compliance’s rules for Data Validation and Selection are set up at Compliance\Setup:

 IP Validation Rules

 IP Validation Rules ICD-10

 OP Validation Rules

 OP Validation Rules ICD-10

 IP Selection Rules

 IP Selection Rules ICD-10

 OP Selection Rules

 OP Selection Rules ICD-10

See the Rules Setting chapter of the Compliance User Guide for more information.

479 Clintegrity Coding/Abstracting User Guide

Regulatory The following edits fall under Regulatory:

 General Validation (see page 481)

 MCE (see page 483)

 ICD 10 MCE (see page 484)

 ICD 10 Relational Code Edits (see page 485)

 Inpatient OIG Target Edits (see page 488)

 Inpatient Transfer DRG Edit (see page 488)

 NCCI (see page 488)

 OCE (Including CCI) (see page 488)

 ICD-10 OCE (Including CCI) (see page 494)

 Medical Unlikely Edits (MUE) (see page 501)

 Nuance OCE additions (see page 501)

 EAPG Edits (see page 501)

480 Appendix F Comparison of Edits

 Medical Review Policies (see page 506)

 ICD-10 Medical Review Policies (see page 506)

Table 119: Regulatory Edits Table

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

General Validation X X X X X

Account Number Unique Within X X X Facility With Similar Visit Type

CM Code Error X X X X

Compare Imported DRG To Original V

CM Sex Conflict X

DRG At Per Diem Rate X

Dx Sex Conflict X

E-Code As Admit Dx X X X

E-Code As Reason for Visit X X

Episode Date Within Allowed No Of X X Days

Maximum Code Error X X X X

Four CM Links For HCPCS Procedure Code

Four Dx Links For HCPCS Procedure Code

HCPCS Procedure Sex Conflict X

Modifier Non-Hospital Approved X X

No Duplicate Condition Codes X V

No Duplicate CM Codes X X V V

No Duplicate Dx Codes X X V V

No Duplicate Encounter V V

No Duplicate HCPCS/CPT Codes X X

No Duplicate Px Codes X X

Required Fields For Complete X X Encounters

481 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

System Required Edits X X V V Edits required to create an encounter – Patient Type, Facility, MRN, Sex, Age, Account Number, Admit Date/Time and Discharge Status

Valid Admit/From Date X X X V V

Valid Bill Type X X X V V

Valid Birth Weight X X V V

Valid Charge Amounts For HCPCS V Px Codes

Valid DRG X V

Valid Date Of Birth X X X V V

Valid Dates X X X V V

Valid Device Code/FB Modifier X X Combination (ASC only)

Valid Device Code/FC Modifier X X Combination (ASC only)

Valid Discharge Status X X

Valid Discharge/To Date X X V V

Valid Dx Code X

Valid CM Code X

Valid Dx Link For HCPCS Procedure Code

Valid Episode Date For Px And X X V V HCPCS Px

Valid HCPCS Procedure Code X

Valid Overnight Stay (ASC only) X X

Valid Payor V V

Valid Provider X X X

Valid Present On Admission(POA) X X X

Valid Procedure Code X V

482 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Valid Service Units For HCPCS X V Procedure Codes

Valid Total Charge X X V V

No Duplicate Lab Codes X X X X

No Duplicate PCS Codes X X X X

PCS Codes Error X X X X

Verify Readmission X X

ICD 10 General Validation X X X X

Valid Present On Admission(POA) X for ICD10

Valid Present On Admission(POA) X Exempt Codes for ICD10

No Duplicate ICD10 Condition code X

Maximum Code Error X

MCE X ------X ---

MCE-01: Invalid Code X V, S

MCE-02: E-Code as Principal X V, S Diagnosis

MCE-03: Duplicate of PDx X V, S

MCE-04: Diagnosis-Age Conflict X V, S

MCE-05: Dx and Px-Sex Conflict X V, S

MCE-06: Manifestation Code As X V, S Principal Dx

MCE-07: Nonspecific Principal X V, S Diagnosis NOTE: MCE 07 is invalid as of October, 2007.

MCE-08: Questionable Admission X V, S

MCE-09: Unacceptable Principal X V, S Diagnosis

483 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

MCE-10: Nonspecific O.R. X V, S Procedure NOTE: MCE 10 is invalid as of October, 2007.

MCE-11: Non-covered Procedure X V, S

MCE-12: Open Biopsy Check X V, S (effective through 9/30/2010 v27)

MCE-13: Bilateral Procedure X V, S

MCE-14: Invalid Age X V, S

MCE-15: Invalid Sex X V, S

MCE-16: Invalid Discharge Status V, S

MCE 17: Limited Coverage

MCE-18: Wrong Procedure X V, S Performed

MCE-19: Procedure inconsistent X V, S with LOS

MCE-20: Combo Heart/Lung X V, S Transplant Procedure

MCE-21: Heart Transplant X V, S Procedure

MCE-22: Implantable Heart Assist X V, S System

MCE-23: Intestine/M. Visceral X V, S Transplant

MCE-24: Liver Transplant X V, S Procedure

ICD 10 MCE X ------X ---

MCE-01: Invalid CM or PCS Codes X V, S

MCE-02: External Causes Of X V, S Morbidity Code As Principal Diagnosis

MCE-03: Duplicate of PCM X V, S

MCE-04: CM Code - Age Conflict X V, S

484 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

MCE-05: CM/PCS - Sex Conflict X V, S

MCE-06: Manifestation Code As X V, S Principal Diagnosis

MCE-07: Nonspecific Principal X V, S Diagnosis/External Causes of morbidity

MCE-08: Questionable Admission X V, S

MCE-09: Unacceptable Principal X V, S Diagnosis

MCE-10: Nonspecific O.R. X V, S Procedure

MCE-11: Non-covered Procedure X V, S

MCE-14: Invalid Age X V, S

MCE-15: Invalid Sex X V, S

MCE-16 - Invalid Discharge Status V, S

MCE-17: Limited Coverage X V, S

MCE-18: Wrong Procedure X V, S Performed

MCE-19: Procedure inconsistent X V, S with LOS

ICD 10 Relational Code Edits X ------X ---

Activity Code (cm83) X X X X

Bilateral Combination (cm35) X X X X

Bilateral Combination (pcs35) X

Cannot be Principal Diagnosis X X X X (cm34)

Cannot be Principal Procedure X X (pcs34)

Code First (cm29) X X X X

Code First Conditional (cm28) X X X X

Code First Generic Conditions X X X X (cm30)

485 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Conditional Code Connection X X X X (cm20)

Excludes1: Mental Health X X X X (cm12_13)

External Cause Status (cm82) X X X X

External Causes Additional Detail X X X X (cm80)

External Causes of Morbidity X X X X (cm84)

HAC (cm37) X X

Incompatible/Illogical (cm12) X X X X

Mandatory Code Connection X X X X (cm21)

Newborn and Perinatal Code Edits X X X X (cm52)

Not IP Code (IP only) (cm38) X

Obstetric Complications (cm09) X X X X

Obstetric and Abortion Conditional X X X X Code Connection (cm07)

Obstetric and Abortion Mandatory X X X X Code Connection (cm08)

Patient Diagnosis Age Variable - X X X X Over Age (cm43)

Patient Diagnosis Age Variable - X X X X Under Age (cm42)

Place of Occurrence (cm85) X X X X

Principal Diagnosis Only (cm04) X X X X

Q-Check Edits X X X X

Procedure Review For CM (pcs22) X X

Procedure and Diagnosis Lateral X X Incompatibility (pcs12)

Review Record for Additional X X Procedure (pcs20)

486 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

PCS review for medical necessity X X CM (CM22_01)

CPT review for medical necessity X X X CM (CM22_02) icd10cm04 - Principal Diagnosis X V, S Only icd10cm07 - Obstetric and Abortion X V, S Conditional Code Connection icd10cm08 - Obstetric and Abortion X V, S Mandatory Code Connection icd10cm09 - Obstetric X V, S Complications icd10cm12 - Incompatible/Illogical X V, S icd10cm20 - Conditional Code X V, S Connection icd10cm21 - Mandatory Code X V, S Connection icd10cm28 - Code First Conditional X V, S icd10cm29 - Code First X V, S icd10cm34 - Cannot be Principal X V, S Diagnosis icd10cm35 - Bilateral Combination X V, S icd10cm37 - HAC (IP only) X V, S icd10cm38 - Not IP Code (IP only) X V, S icd10cm42 - Patient Diagnosis Age X V, S Variable - Over Age icd10cm43 - Patient Diagnosis Age X V, S Variable - Under Age icd10cm52 - Newborn and Perinatal X V, S Code Edits icd10cm80 - External Causes X V, S Additional Detail icd10cm82 - External Cause Status X V, S

487 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

icd10cm83 - Activity Code X V, S

icd10cm84 - External Causes of X V, S Morbidity and Place of Occurrence

icd10pcs34 - Cannot be Principal X V, S Procedure

icd10pcs35 - Bilateral Combination X V, S

Inpatient OIG Target ------X ---

Inpatient OIG Target Edits S

Inpatient Transfer DRG Edit S

NCCI ------X ------

NCCI-01: With and Without X Procedures

NCCI-02: Anesthesia included X

NCCI-03: Comprehensive X procedure

NCCI-04: See Manual X

NCCI-05: Check code definition X

NCCI-06: Sex Conflict X

NCCI-07: Included in Lab panel X

NCCI-08: Misuse of Codes X

NCCI-09: Lesser procedure X

NCCI-10: Mutually Exclusive X Procedures

NCCI-11: Code Second Procedure X

NCCI-12: Service Routinely X included

NCCI-13: Service routinely provided X

OCE (Including CCI) X X ------X Only OCE 3, 8 and 22

OCE-01: Invalid diagnosis code X V, S

488 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-02: Diagnosis and age conflict X V, S

OCE-03: Diagnosis and sex conflict X V, S

OCE-04: (NOT ACTIVATED BY N/A N/A CMS!) Medicare secondary payer alert (V1.0 and V1.1 only)

OCE-05: E- code can not be used X V, S as principal dx

OCE-06: Invalid HCPCS procedure X V, S code

OCE-07: (NOT ACTIVATED BY N/A N/A CMS!) HCPCS procedure and age conflict

OCE-08: HCPCS procedure and X X V, S sex conflict

OCE-09: Non-covered for reasons X V, S other than statute

OCE-10: Service submitted for X V, S verification of denial (condition code 21)

OCE-11: Service submitted for X V, S review (condition code 20)

OCE-12: Questionable covered X V, S service

OCE-13: Separate payment for X V, S services is not provided by Medicare

OCE-14: Code indicates a site of X V, S service not included in OPPS

OCE-15: Service unit out of range X V, S for procedure (V1.0 through V2.2 only)

OCE-16: Multiple bilateral X V, S procedures without modifier 50

OCE-17: Inappropriate specification X V, S of bilateral procedure

OCE-18: Inpatient procedure X V, S

489 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-19: Mutually exclusive X V, S procedure code (Code2) is not allowed with code (Code1) by CCI even if appropriate modifier is present (OCE-19) (CCI)

OCE-20: Code (Code2) of a code X V, S pair is not allowed with code (Code1) by CCI even if appropriate modifier is present (OCE-20) (CCI)

OCE-21: Medical visit on same day X V, S as a type T or S procedure without modifier 25

OCE-22: Invalid modifier X X V, S

OCE-23: Invalid HCPCS service X V, S date

OCE-24: From date out of OCE X V, S range, it must be on or after July 1, 1987 and on or before the processing date

OCE-25: Invalid age. Age must be X V, S between 0 and 124 years

OCE-26: Invalid sex X V, S

OCE-27: Only incidental services X V, S reported

OCE-28: Code not recognized by X V, S Medicare; alternate code for same service available

OCE-29: Partial Hospitalization X V, S service for non-mental health diagnosis

OCE-30: Insufficient services on X V, S day of partial hospitalization

OCE-31: Partial hospitalization on X V, S same day as electro convulsive therapy or type T procedure

OCE-32: Partial hospitalization X V, S encounter spans 3 or less days with insufficient services

490 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-33: Partial hospitalization X V, S encounter spans more than 3 days with insufficient number of days having mental health services

OCE-34: Partial hospitalization X V, S encounter spans more than 3 days with insufficient number of days meeting partial hospitalization criteria

OCE-35: Only Mental Health X V, S education and training services provided

OCE-36: Extensive Mental Health X V, S services provided on day of ECT or Type T procedure

OCE-37: Terminated bilateral X V, S procedure or terminated procedure with units greater than one

OCE-38: Inconsistency between X V, S implanted device and implantation procedure

OCE-39: Mutually exclusive X V, S procedure code (Mut2) that would be allowed with code (Mut1) by CCI if appropriate modifier were present (OCE-39) (CCI)

OCE-40: Code (Code2) of a code X V, S pair would be allowed with code (Code1) by CCI if appropriate modifier were present (OCE-40) (CCI)

OCE-41: Invalid revenue code X V, S

OCE-42: Multiple medical visits on X V, S same day with same RC without condition code G0

OCE-43: Transfusion or blood X V, S product exchange without specification of blood product

491 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-44: Observation revenue code X V, S on line item with non-observation HCPCS code

OCE-45: Inpatient separate X V, S procedures not paid

OCE-46: Partial Hospitalization X V, S condition code 41 not approved for type of bill

OCE-47: Service not separately X V, S payable

OCE-48: Revenue center requires X V, S HCPCS

OCE-49: Service with inpatient X V, S procedure

OCE-50: Non-covered based on X V, S statutory exclusion

OCE-51: (NOT YET ACTIVATED N/A N/A BY CMS!) Multiple observations overlap in time

OCE-52: Observation does not X V, S meet criteria for separate payment

OCE-53: Observation G codes only X V, S allowed with bill type 13X

OCE-54: Multiple codes for the X V, S same service

OCE-55: Non-reportable for site of X V, S service

OCE-56: E&M or ancillary X V, S conditions not met and G0244 date is not 12/31 or 1/1

OCE-57: E&M or ancillary X V conditions not met and G0244 date is 12/31 or 1/1

OCE-58: G0263 only allowed with X V, S payable G0244

492 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-59: Clinical trial requires DX X V, S code V707 as other than principal DX

OCE-60: Use of modifier CA with X V, S more than one procedure not allowed

OCE-61: This code can only be X V, S billed to the DMERC

OCE-62: Code not recognized by X V, S OPPS, alternate code for same service may be available

OCE-63: This OT code only billed X V, S on PH claims

OCE-64: AT service is not payable X V, S outside the partial hospitalization program

OCE-65: Revenue code not X V, S recognized by Medicare

OCE-66: Code requires manual X V, S pricing

OCE-67: Service provided prior to X V, S FDA approval/NCD date

OCE-68: Service provided prior to X V, S date of NCD approval

OCE-69: Service provided outside X V, S approval period

OCE-70: CA modifier requires X V, S patient status code 20

OCE-71: Claim lacks required X V, S device code

OCE-72: Service not billable to the X V, S Fiscal Intermediary.

OCE-73: Incorrect billing of blood X V, S and blood products

OCE-74: Units greater than one for X V, S bilateral procedure billed with modifier 50

493 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-75: Incorrect billing of modifier X V, S FB or FC

OCE-76: Trauma response critical X V, S care code without revenue code 68x and CPT 99291

OCE-77: Claim lacks allowed X V, S procedure code (for coded device)

OCE-78: Claim lacks required X V, S radiopharmaceutical

OCE-79: Incorrect billing of revenue X V, S code with HCPCS code

OCE-80: Mental health code not X V, S approved for partial hospitalization

OCE-81: Mental health service not X V, S payable outside the partial hospitalization program

OCE-82: Charge exceeds token X V, S charge ($1.01)

OCE-83: Service provided on or X V, S after effective date of NCD non-coverage

OCE-86 - Manifestation code not X V, S allowed as principal diagnosis (RTP)

OCE-87 - Skin substitute X V, S application procedure without appropriate skin substitute product code

ICD-10 OCE (Including CCI) X X ------X Only OCE 3, 8 and 22

OCE-01: Invalid CM code X V, S

OCE-02: CM and age conflict X V, S

OCE-03: CM and sex conflict X V, S

OCE-04: (NOT ACTIVATED BY N/A N/A CMS!) Medicare secondary payer alert (V1.0 and V1.1 only)

494 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-05: External Cause code can X V, S not be used as principal diagnosis

OCE-06: Invalid procedure code X V, S

OCE-07: (NOT ACTIVATED BY N/A N/A CMS!) procedure and age conflict

OCE-08: Procedure and sex conflict X X V, S

OCE-09: Non-covered under any X V, S Medicare Outpatient benefit, for reasons other than statutory exclusion

OCE-10: Service submitted for X V, S denial (condition code 21)

OCE-11: Service submitted for X V, S FI/MAC review (condition code 20)

OCE-12: Questionable covered X V, S service

OCE-13: (NOT ACTIVATED BY X V, S CMS!) Separate payment for services is not provided by Medicare

OCE-14: (NOT ACTIVATED BY X V, S CMS!) Code indicates a site of service not included in OPPS

OCE-15: Service unit out of range X V, S for procedure (V1.0 through V2.2 only)

OCE-16: (NOT ACTIVATED BY X V, S CMS!) Multiple bilateral procedures without modifier 50

OCE-17: Inappropriate specification X V, S of bilateral procedure

OCE-18: Inpatient procedure X V, S

OCE-19: Mutually exclusive X V, S procedure that is not allowed by NCCI even if appropriate modifier is present

495 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-20: Code 2 of a code pair that X V, S is not allowed by NCCI even if appropriate modifier is present

OCE-21: Medical visit on the same X V, S day as a type T or S procedure without modifier 25

OCE-22: Invalid modifier X X V, S

OCE-23: Invalid HCPCS service X V, S date

OCE-24: Date out of OCE range X V, S

OCE-25: Invalid age. Age must be X V, S between 0 and 124 years

OCE-26: Invalid sex X V, S

OCE-27: Only incidental services X V, S reported

OCE-28: Code not recognized by X V, S Medicare for outpatient claims; alternate code for same service available

OCE-29: Partial hospitalization X V, S service for non-mental health diagnosis

OCE-30: Insufficient services on X V, S day of partial hospitalization

OCE-31: (NOT ACTIVATED BY X V, S CMS!) Partial hospitalization on same day as ECT therapy or type T procedure

OCE-32: (NOT ACTIVATED BY X V, S CMS!) Partial hospitalization claim spans more than 3 days with insufficient number of days having partial hospitalization services

OCE-33: (NOT ACTIVATED BY X V, S CMS!) Partial hospitalization encounter spans more than 3 days with insufficient number of days having mental health services

496 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-34: (NOT ACTIVATED BY X V, S CMS!) Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria

OCE-35: (Content not yet available) X V, S Only Mental Health education and training services provided

OCE-36: (NOT ACTIVATED BY X V, S CMS!) Extensive Mental Health services provided on day of ECT or Type T procedure

OCE-37: Terminated bilateral X V, S procedure or terminated procedure with units greater than one

OCE-38: Inconsistency between X V, S implanted device or administered substance and implantation or associated procedure

OCE-39: Mutually exclusive X V, S procedure code (Mut2) that would be allowed with code (Mut1) by CCI if appropriate modifier were present (OCE-39) (CCI)

OCE-40: Code2 of a code pair that X V, S would be allowed by NCCI if appropriate modifier were present

OCE-41: Invalid revenue code X V, S

OCE-42: Multiple medical visits on X V, S same day with same RC without condition code G0

OCE-43: Transfusion or blood X V, S product exchange without specification of blood product

OCE-44: Observation revenue code X V, S on line item with non-observation HCPCS code

OCE-45: Inpatient separate X V, S procedures not paid

497 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-46: Partial hospitalization X V, S condition code 41 not approved for type of bill

OCE-47: Service is not separately X V, S payable

OCE-48: Revenue center requires X V, S HCPCS

OCE-49: Service on same day as X V, S inpatient procedure

OCE-50: Non-covered under any X V, S Medicare output benefit based on statutory exclusion

OCE-51: (NOT YET ACTIVATED N/A N/A BY CMS!) Multiple observations overlap in time

OCE-52: (NOT ACTIVATED BY X V, S CMS!) Observation does not meet minimum hours, qualifying diagnoses, and/or T procedure conditions

OCE-53: Codes G0378 and G0379 X V, S only allowed with bill type 13X or 85X

OCE-54: Multiple codes for the X V, S same service

OCE-55: Non-reportable for site of X V, S service

OCE-56: (NOT ACTIVATED BY X V, S CMS!)E/M condition not met and line item date for observation code G0244 is not 12/31 or 1/1

OCE-57: Composite E/M condition X V not met for observation and line item date for code G0378 is 1/1

OCE-58: G0379 only allowed with X V, S G0378

498 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-59: (NOT ACTIVATED BY X V, S CMS!) Clinical trial requires DX code V707 as other than principal DX

OCE-60: Use of modifier CA with X V, S more than one procedure not allowed

OCE-61: This code can only be X V, S billed to the DMERC

OCE-62: Code not recognized by X V, S OPPS, alternate code for same service may be available

OCE-63: (NOT ACTIVATED BY X V, S CMS!) This OT code only billed on partial hospitalization claims

OCE-64: (NOT ACTIVATED BY X V, S CMS!) AT service is not payable outside the partial hospitalization program

OCE-65: Revenue code not X V, S recognized by Medicare

OCE-66: Code requires manual X V, S pricing

OCE-67: Service provided prior to X V, S FDA approval

OCE-68: Service provided prior to X V, S date of National Coverage Determination (NCD) approval

OCE-69: Service provided outside X V, S approval period

OCE-70: CA modifier requires X V, S patient status code 20

OCE-71: Claim lacks required X V, S device code

OCE-72: Service not billable to the X V, S Fiscal Intermediary/Medicare Administrative Contractor.

499 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-73: Incorrect billing of blood X V, S and blood products

OCE-74: Units greater than one for X V, S bilateral procedure billed with modifier 50

OCE-75: Incorrect billing of modifier X V, S FB or FC

OCE-76: Trauma response critical X V, S care code without revenue code 68x and CPT 99291

OCE-77: Claim lacks allowed X V, S procedure code

OCE-78: (DEACTIVATED BY CMS X V, S EFFECTIVE 01/01/2014!) Claim lacks required radiolabeled product

OCE-79: Incorrect billing of revenue X V, S code with HCPCS code

OCE-80: Mental health code not X V, S approved for partial hospitalization

OCE-81: Mental health service not X V, S payable outside the partial hospitalization program

OCE-82: Charge exceeds token X V, S charge ($1.01)

OCE-83: Service provided on or X V, S after effective date of NCD non-coverage

OCE-84 - Claim lacks required X V, S primary code

OCE-85 - (DEACTIVATED BY CMS X V, S EFFECTIVE 01/01/2014!) Claim lacks required primary device code or required procedure code

OCE-86 - Manifestation code not X V, S allowed as principal diagnosis (RTP)

500 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

OCE-87 - Skin substitute X V, S application procedure without appropriate skin substitute product code

Medical Unlikely Edits (MUE) X X V, S

Nuance OCE additions --- X ------

Nuance OCE-02: Invalid Thru date X V, S

EAPG Edits X V

E-3001: Invalid Diagnosis Code X V

E-3002: Diagnosis and Age Conflict X V

E-3003: Diagnosis and Sex Conflict X V

E-3005: E-diagnosis code cannot X V be used as principal diagnosis

E-3006: Invalid Procedure Code X V

E-3008: Procedure and Sex Conflict X V

E-3017: Inappropriate specification X V of bilateral procedure

E-3018: Service considered an X V inpatient procedure

E-3019: NCCI - Mutually exclusive X V with code 'XXXXX' and is not allowed even if appropriate modifier is present

E-3020: NCCI - This code is a X V component of comprehensive procedure 'XXXXX' and is not allowed even if appropriate modifier is present

E-3022: Modifier 'XX' is invalid X V

E-3023: Invalid date X V

E-3024: Date of service is out of X V date range for grouper

E-3025: Invalid age X V

E-3026: Invalid sex X V

501 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

E-3037: Terminated bilateral X V procedure or terminated procedure with units greater than one

E-3039 NCCI: Mutually exclusive X V procedure with procedure 'XXXXX' that is allowed if an appropriate NCCI modifier is present

E-3040 NCCI: This code is a X V component of comprehensive procedure 'XXXXX' that is allowed if an appropriate NCCI modifier is present

E-3041: Revenue code 'XXXX' is X V invalid

E-3074: Units of service greater X V than one is inappropriate for bilateral procedure reported with modifier 50 NOTE: Units of service field accept numbers with up to three decimal points.

E-3101: Invalid diagnosis code, 4th X V or 5th digit required

E-3102: Invalid diagnosis code X V

E-3103: Age conflict - diagnosis X V considered only for newborns, age <1 year

E-3104: Age conflict - diagnosis X V considered only for pediatric patients, age <18 years

E-3105: Age conflict - diagnosis X V considered only for maternity, females 12-55 years

E-3106: Age conflict - diagnosis X V considered only for adults, age 15 and up

E-3107: Sex conflict - diagnosis X V code is only valid for male patients

502 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

E-3108: Sex conflict - diagnosis X V code is only valid for female patients

E-3111: Sex conflict - procedure X V only valid for male patients

E-3112: Sex conflict - procedure X V only valid for female patients

E-3115: From date is invalid or X V blank. This is a required field

E-3116: Through date is invalid or X V blank. This is a required field

E-3117: Line item service date is X V invalid or blank. This is a required field

E-3118: Line item service date is X V not within the from-through dates

E-3119: From date cannot be after X V through date

E-3120: Terminated bilateral X V procedure. Do not use modifier -50 when reporting a terminated procedure

E-3121: Terminated procedure with X V units greater than one. Do not use multiple units when reporting a terminated procedure

E-3122: Primary diagnosis code is X V blank; must be a valid code

E-3124: Duplicate lab or pathology X V code. Add modifier -59 or -91 if documentation supports use. Otherwise duplicate code may not be paid

E-3128: Duplicate radiology code. X V Add modifier if documentation supports use to differentiate services. Otherwise duplicate code may not be paid

503 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

E-3129: Presence of an anatomic X V site modifier on this or codes XXXXX, XXXXX, XXXXX is suppressing NCCI edit. Check documentation to determine whether both code pairs can be billed or an additional site modifier added

E-3130: Presence of the same X V anatomic site modifier on this and codes XXXXX, XXXXX, XXXXX is suppressing NCCI edit. Check documentation to verify use of same modifier. Otherwise one of the codes may not be paid

E-3132: Inherent bilateral code, X V report code once. Do not report with modifier -50

E-3135: Inherent bilateral X V procedure. Consider removing modifier -50 from this cod

E-3143: Duplicate lab or pathology X V code. Add modifier -59 or -91 if documentation supports use. Otherwise duplicate code may not be paid

E-3144: Add-on code reported X V without base procedure XXXXX, XXXXX-XXXXX

E-3319: This mutually exclusive X V code pair is paired with another CPT code to trigger edit 3019

E-3320: This comprehensive code X V is paired with another CPT component code to trigger edit 3020

E-3339: This mutually exclusive X V code pair is paired with another CPT code to trigger edit 3039

E-3340: This comprehensive code X V is paired with another CPT component code to trigger edit 3040

504 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

E-3600: Corneal transplant coded. X V Ensure that if appropriate, acquisition of the corneal tissue is also coded

E-3601: Transfusion is coded. X V Ensure that blood and blood products transfused are also coded

E-3602: Brachytherapy is coded. X V Ensure that brachytherapy seeds or radioelement is also coded

E-3603: Nuclear medicine is coded. X V Ensure that therapeutic radiopharmaceuticals used in nuclear medicine procedures are also coded

E-3604: Infusion therapy is coded. X V Ensure that the substance infused is also coded

E-3605: Chemotherapy is coded. X V Ensure that chemotherapeutic agents and other supportive drugs are also coded

E-3606: Vaccination is coded. X V Ensure that the vaccine administered is also coded

E-3607: Injection is coded. Ensure X V that the substance injected is also coded

E-3609: Lens implant is coded. X V Ensure that the intraocular lens is also coded if applicable

E-3610: Neurostimulator X V implantation is coded. Ensure that the neurostimulator is also coded

E-3611: Insertion of prosthesis is X V coded. Ensure that the penile prosthesis is also coded

E-3613: Radiology procedure with X V contrast is coded. Ensure that the contrast material is also coded

505 Clintegrity Coding/Abstracting User Guide

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

E-3614: Interventional radiology X V procedure is coded. Ensure that the surgical intervention is also coded

E-3615: A 3D rendering radiology X V procedure is coded. Ensure that the base radiology procedure is also coded

Medical Review Policies

NCD and LCD X V, S (National Coverage Decision and Local Coverage Determination)

ICD-10 Medical Review Policies

NCD and LCD X V, S

(National Coverage Decision and Local Coverage Determination)

Data Quality Edits

Table 120: Data Quality Edits Table

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Relational Code Edits ------

Inpatient Relational Code Edits X V, S

Outpatient Relational Code Edits X V, S

Dx/HCPCS Linkage S

HCPCS Protocol S

Inpatient Data Quality S

Modifier Code Edits

Non Hospital Approved X X V, S

Modifier Conflict X X V, S

Modifier Code Conflict X X V, S

Required Diagnosis Code X X V, S

506 Appendix F Comparison of Edits

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Required Modifier X X V, S

Requires Multiple Codes X X V, S

ICD9 Relational Edits X X V, S V, S

CPT Relational Edits X X X V, S

ICD 10 PSI Edits X X

ICD 10 IP Compliance Selection Rules

CC/MCC X

Non-Specific Diagnosis X

Mechanical Ventilation X

Principal Diagnosis Selection X

Postop Complication X

Short Stay X

Transfer DRG X

Trauma X

PCS Selection Rules by MDC X Pre-25

ICD9 ECode Edits

ICD9 ECode Edits X X V, S V, S

ICD9 Ecode Place of Occurrence X X V, S V, S Edits

QCheck Edits Category X X X V, S V, S

QCheck Edits X X X V, S V, S

QCheck ICD-9 and ICD-10 DRG X X X V, S V, S inconsistency

507 Clintegrity Coding/Abstracting User Guide

Revenue Edits

Table 121: Revenue Edits Table

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Revenue Edits S

Custom Rules

Table 122: Custom Rules Table

FACILITY FACILITY PHYSICIAN COMPLIANCE COMPLIANCE RULE NAME CODING IP CODING OP CODING IP OP

Custom Rules S S

508 Appendix G Coding Acronyms

Appendix G  Coding Acronyms

Table 123: Coding Acronyms

ACRONYM DESCRIPTION

3M™ 3M™ Health Information System

AD Admission Date

AHA American Hospital Association

AHIMA American Health Information Management Association

AMA American Medical Association

AMLOS Arithmetic Mean Length of Stay

APC Ambulatory Patient Classification

APR All Patient Refined

APR-DRG All Patient Refined Diagnosis Related Group

ASC Ambulatory Surgery Center

ASCII American Standard Code for Information Interchange

CC Complication and Comorbidity

CDR Coder Disk Reference

CLU Clinical Language Understanding

CM ICD-10 Diagnosis Code (Clinical Modification)

CMHC Community Mental Health Centers

CMS Center for Medicare and Medicaid Services

CPT Current Procedural Terminology

CT Scan Computerized Tomography

DHHS Department of Health and Human Services

DD Discharge Date

DRG Diagnosis Related Group

Dx ICD-9 Diagnosis Code

E-Codes External Cause of Injury Codes

509 Clintegrity Coding/Abstracting User Guide

ACRONYM DESCRIPTION

EAPG Enhanced Ambulatory Payment Group

EDM Electronic Document Management

FD From Date

FTE Full Text Entry

GEM General Equivalency Mappings

GMLOS Geometric Mean Length of Stay

HCPCS Healthcare Common Procedure Coding System

HTTP Hyper Text Transfer Protocol

ICD International Classification of Diseases

IP Inpatient

IPPS Inpatient Prospective Payment System

LCD Local Coverage Decisions

LOS Length of Stay

LTCH Long Term Care Hospital

MCC Major Complication and Comorbidity

MCE Medicare Code Editor

MDC Major Diagnostic Category

MRN Medical Record Number

MS-DRG Medicare Severity Diagnosis Related Group

MTD Month To Date

NCD National Coverage Decisions

NCCI National Correct Coding Initiative

NCHS National Center for Health Statistics

OCE Outpatient Code Editor

OIG Officer of Inspector General

OP Outpatient

OPPS Outpatient Prospective Payment System

OSHPD Office of Statewide Health Planning and Development

PCS ICD-10 Procedure Code (Procedure Classification System)

510 Appendix G Coding Acronyms

ACRONYM DESCRIPTION

PET Positron Emission Tomographic

PCM ICD-10 Principal Diagnosis Code

PDx ICD-9 Principal Diagnosis Code

POA Present On Admission

PSI Patient Safety Indicator

PT Patient Type

Px ICD-9 Procedure Code

RAC Recovery Audit Contractor

ROM Risk of Mortality

RTP Return to Provider

SOI Severity of Illness

TD To Date

UHDDS Uniform Hospital Discharge Data Set

XML Extensible Markup Language

YTD Year To Date

511 Clintegrity Coding/Abstracting User Guide

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512 Appendix H Location of ICD10 General Validation edits within ICD9 General Validation

Appendix H  Location of ICD10 General Validation edits within ICD9 General Validation

To navigate to General Validation Rules for IP Rule Settings, go to Coding/Abstracting\Setup\IP Rule Settings (Complete/Incomplete) Encounters \Regulatory. General Validations rules for IP Rules Settings are displayed.

Table 124: General Validation Rules for IP Rule Settings

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Account Number Unique Within Facility With Similar Visit X Type

CM Code Error X

DRG At Per Diem Rate X

E-Code As Admit Dx X

Episode Date Within Allowed No Of Days X

Maximum Code Error X

Modifier Non-Hospital Approved X

No Duplicate CM Codes X

No Duplicate Condition Codes X

No Duplicate Dx Codes X

No Duplicate HCPCS/CPT Codes X

No Duplicate Lab Codes X

No Duplicate PCS Codes X

No Duplicate Px Codes X

PCS Codes Error X

Required Fields For Complete Encounters X

Valid Admit/From Date X

513 Clintegrity Coding/Abstracting User Guide

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Valid Bill Type X

Valid Birth Weight X

Valid Dates X

Valid Discharge Status X

Valid Discharge/To Date X

Valid Episode Date For Procedures And HCPCS Procedures X

Valid Hcpcs Procedure Code X

Valid Present On Admission(POA) X

Valid Present On Admission(POA) Exempt Codes X

Valid Provider X

Valid Service Units For HCPCS Procedure Codes X

Valid Total Charges X

Verify Readmission X

To navigate to General Validation Rules for OP Rule Settings, go to Coding/Abstracting\Setup\OP Rule Settings (Complete/Incomplete) Encounters \Regulatory. General Validations rules for OP Rules Settings are displayed.

Table 125: General Validation Rules for OP Rule Settings

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Account Number Unique Within Facility With Similar Visit X Type

CM Code Error X

E-Code As Admit Dx X

E-Code As Reason for Visit X

Eight CM Links For HCPCS Procedure Code X

Eight Dx Links For HCPCS Procedure Code X

Maximum Code Error X

514 Appendix H Location of ICD10 General Validation edits within ICD9 General Validation

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Modifier Non-Hospital Approved X

No Duplicate CM Codes X

No Duplicate Condition Codes X

No Duplicate Dx Codes X

No Duplicate HCPCS/CPT Codes X

No Duplicate ICD10 RV Codes X

No Duplicate Lab Codes X

No Duplicate PCS Codes X

No Duplicate Px Codes X

No Duplicate RV Codes X

PCS Codes Error X

PCS Sex Conflict X

Required Fields For Incomplete Encounters X

System Required Fields X

Valid Admit/From Date X

Valid Bill Type X

Valid Birth Weight X

Valid CM Link For HCPCS Procedure Code X

Valid Date Of Birth X

Valid Dates X

Valid Device Code/FB Modifier Combination (ASC only): X

Valid Device Code/FC Modifier Combination (ASC only): X

Valid Discharge Status X

Valid Discharge/To Date X

Valid Dx Link For HCPCS Procedure Code X

Valid Episode Date For Procedures X

Valid Overnight Stay (ASC only) X

Valid Payor X

515 Clintegrity Coding/Abstracting User Guide

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Valid Present On Admission(POA): X

Valid Procedure Code X

Valid Provider X

Valid Service Units For HCPCS Procedure Codes X

Valid Total Charges X

NOTE: The OCE edits and Data Quality edits are all specific to ICD-9 To navigate to General Validation Rules for Physician Rule Settings, go to Coding/Abstracting\Setup\Physician Rule Settings (Complete/Incomplete) Encounters \Regulatory. General Validations rules for Physician Rules Settings are displayed.

Table 126: General Validation Rules for Physician Rule Settings

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Account Number Unique Within Facility With Similar Visit X Type

CM Sex Conflict X

Dx Sex Conflict X

E-Code As Admit Dx X

Eight CM Links For HCPCS Procedure Code X

Eight Dx Links For HCPCS Procedure Code X

Episode Date Within Allowed No Of Days X

HCPCS Procedure Sex Conflict X

No Duplicate CM Codes X

No Duplicate Dx Codes X

Required Fields For Complete Encounters X

Requires Service Date X

Valid Admit/From Date X

Valid CM Code X

516 Appendix H Location of ICD10 General Validation edits within ICD9 General Validation

ICD-9 ICD-10 ICD-9 RULE AND ONLY ONLY ICD-10

Valid CM Link For HCPCS Procedure Code X

Valid Date Of Birth X

Valid Dates X

Valid Discharge Status X

Valid Discharge/To Date X

Valid Dx Code X

Valid Dx Link For HCPCS Procedure Code X

Valid Episode Date For Procedures And HCPCS Procedures X

Valid Hcpcs Procedure Code X

Valid Present On Admission(POA) X

Valid Provider X

Valid Service Units For HCPCS Procedure Codes X

NOTE: NCCI edits and Data Quality edits are all specific to ICD-9. For Custom rules, rules enterprise or group rules are shown in Compliance set up and are not filtered out if the setup is for ICD-9 or ICD-10.

517 Clintegrity Coding/Abstracting User Guide

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518 Index Index

A code builder explained 289 abstracting screen order 68 using 295 abstracting summary form 418 code connection 249 encounter keywords 419 code modifiers 289 general keywords 419 code packages add charge modifiers 290 creating or changing 81 additional procedure information using 293 entering info 301 codelist, adding to ADx codes, adding to the codelist 292 ADx codes 292 alternate descriptions codes 291 creating or changing 83 CPT codes 292 alternate DRGs 314 ICD9 codes 292 linked codes from index 293 amendments 158 linked codes from tabular 293 APCs see also additional procedure information calculating 307 codelist, modifying codes detail 309 changing a description 351 APR DRG details 312 changing modifier 300 ASCs, calculating 310 changing order 300 copying codes from the Dx to the ADx 298 deleting 300 B codes batch exports, scheduling 134 copy between encounters 188 shuffling 310 batch imports, scheduling 132 coding brackets 293 system information, export 71 browser system information, import 70 custom links, setting 13 coding clinic for HCPCS reference 277 print page options, setting 11 recommended options, setting 11 coding clinic reference 271 coding summary form 364 encounter keywords 366 C general keywords 365 confidentiality, encounter 163 calculate APCs 307 Clintegrity configure IP rule settings ICD-10 110 signing in 14 context menu 258 starting the application 14 context menu in codebooks 258 Clintegrity 360 | EDM CPT assistant reference 273 work with electronic documents 191 CPT codes Clintegrity Coding adding to the codelist 292 completing coding process 192 code modifiers 289 components of 3 CPT procedure index synonyms 439 designations 4 creating essentials 3 alternate description 83 Clintegrity EDM code packages 81 accessing 190 custom references 129 CMS smartips 77 code modifiers 289 synonyms 73 code books cross references appendices 255 in indexes 219 General Equivalency Mappings (GEM) 252 linking to 237 ICD-10 CM 220 Crosswalk 245 tables in the ICD-10 CM diagnosis index 223

519 Clintegrity Coding/Abstracting User Guide custom links, setting 13 read-only 87 custom references required 87 creating 129 file layouts 126 customizing financial information on patient encounter 183 keywords for encounter forms 363 Find All-Tabular search 221 form creating 198 D printing 198 deleting encounters 195 Document List Panel 21 G DRG Pro closing 317 General Keywords 430 explained 314 generating reimbursement amounts 307 using 314 global preferences 69 DRGs grouping an encounter 307 APR DRG details 312 using alternate 314 Drug Guide reference 276 H Hypertension table 238 E editor I edit messages, viewing 304 quality checks 303 ICD-10 Abstracting Summary Form 425 reviewing edits 303 Encounter Keywords 426 using 303 General Keywords 425 electronic documents (QEDM), working with 190 ICD-10 Coding Summary Form 371 Encounter Keywords 431 Encounter Keywords 372 General Keywords 371 encounters adding 162 ICD-10 Inpatient Billing Form 375 administrative information 182 Encounter Keywords 376 copy codes between two 188 General Keywords 375 deleting 195 ICD-10 Outpatient Billing Form 379 demographic data 182 Encounter Keywords 380 exporting 193 General Keywords 379 financial information 183 ICD-10 Physician Attestation Form 383 grouping 307 Encounter Keywords 385 history of 164 General Keywords 384 history, viewing 187 ICD10DataQuality Feature 113, 117 import 168 ICD-9 list of encounters 175 codes, adding to the codelist 292 list of patient’s encounters 161 Coding Guidelines 274 new 179 procedure index synonyms 453 notes 185 opening existing 180 import patient information, entering 181 batch imports 132 pricing 307 coding system information 70 reassigning 163 encounters 168 saving 192 indexes searching for 173 acting on terms you find 237 visit information 182 cross references 219 working with 167 features 201 etiology of disease, linked codes 244 linking to a cross reference 237 linking to tabular 237 export navigating 216 coding system information 71 selection in 212 tables in the ICD9 diagnosis index 238 using 237 F viewing additional information for a term 237 facility preferences 53 visual overview 201, 202 fields Inpatient Billing Form 388

520 Index

Encounter Keywords 390 P General Keywords 389 Interface, Real-time 171 passwords, rules for 16 IP Rule Settings ICD-10 (Complete patient Encounters) 115 add information 143 IP Rule Settings ICD-10 (Incomplete adding 143 amendments 158 Encounters) 115 change information 143 encounter list 161 look up a patient 141 K restrictions 159 keyboard patient information moving through index or tabular 216 data collected 140 keywords for custom encounter forms 363 overview 139 Physician Attestation Form 399 Encounter Keywords 403 L General Keywords 399, 401 linked codes Physician Billing Form etiology with manifestation 244 Encounter Keywords 408 General Keywords 407 logging in 14 Physician Query Form Encounter Keywords 414 M General Keywords 412 Physician Query Form General Keywords 412 manifestation of disease pricing an encounter 307 linked codes 244 print page options, setting 11 MCE Feature for IP Rule Settings ICD-10 111 Complete Encounters 112 procedure codes Incomplete Encounters 112 adding additional information 301 Medical Dictionary reference 277 medicare code edits 303 Q modifiers CMS 289 Q Link mouse term 256 navigating tabular or index 216 quality checks, using the editor 303 MUE, Medical Unlikely Edits 97, 100, 108, 121, 501 R read-only fields 87 N Real-time Interface 171 Navigating With Icons 41 reason for visit 288 Neoplasm table 239 copying 299 Notes 185 recommended browser options, setting 11 reference books Abbreviations & Acronyms 278 O Anatomy 262 Clinical Indicators 270 obstetric edits 303 clinical indicators 270 online help coder’s desk 283 using 45 Coding Clinic 271, 277 OP Rule Settings ICD-10 (Complete coding clinic 271 Encounters) 119 coding clinic for HCPCS 277 OP Rule Settings ICD-10 (Incomplete CPT assistant 273 Encounters) 119 Drug Guide 276 Outpatient Billing Form Faye Brown 280 ICD-10 CM coding guidelines 263 Encounter Keywords 395 ICD-10 coding handbook 281 General Keywords 394 ICD-10 PCS guidelines 269 outpatient code edits 303 ICD-10 PCS reference manual 268 ICD-9 Coding 274 Medical Dictionary 277

521 Clintegrity Coding/Abstracting User Guide

navigating within 259 getting help 16 references, custom 129 how to 14 reports, by category passwords 16 APC reports 330 standard synonyms 439 APR DRG reports 333 synonyms Custom Coding reports 332 in CPT procedure index 439 DRG reports 331 in ICD9 procedure index 453 Encounter reports 330 standard 439 Encounter Status reports 333 HL7 reports 333 Physician Coding reports 332 T Productivity reports 332 tables in the ICD9 diagnosis index reports, working with Hypertension 238 processing reports 320 Neoplasm 239 scheduling reports 323 tabulars required fields 87 acting on entries 243 restrictions 159 additional information for a code 244 rules setup details, viewing for a term 244 compliance IP 89, 93 features 201 compliance IP rules 89, 93 linking to from index 237 compliance OP 96, 99 navigating 216 compliance rules setup 89 searching for codes in 240, 241 configuring rules settings 99 selection in 212 IP rules settings 103 tabular details for a term 244 OP rules settings 106, 116 using 240 physician rules settings 120, 123 visual overview 206 target DRGs finding codes that fulfill unmet S requirements 317 schedule requirements 316 batch exports 134 batch imports 132 U scheduling reports 323 screen order for abstracting 68 user preferences 47 searching users codes in tabulars 240, 241 configuring 19 comma delimited search 473 find all search 473 general search information 471 V multiple term search 472 visit characteristics on patient encounter 182 single term search 471 tips for comma delimited searching 473 tips for FTE searching 472 W sequence ASCs 310 setup worklists abstracting screen order 68 configuring 19 Alternate Description 83 Code Packages 81 visit characteristics on patient encounter 168 custom references 129 determine shuffle settings 63 facility preferences 53 file layouts 126 global preferences 69 required and read-only fields 87 Smartips 77 synonyms 73 user preferences 47 shuffling codes determine settings 63 in Coding 310 signing in

522 Index

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523