David Taylor MHS, RPh, PA-C, RN

2014 RPMS EHR HIM & Coding

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2014 RPMS HER CEHRT HIM & Coding Overview

• HIM Impact and Coding Lessons Learned SNOMED CT

• RPMS EHR Software Changes affecting HIM and Coding

• Integrated Problem List (IPL) and Impact on Coding

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Prepared by Dujuanna Bissonnette, RHIT, CPC Phoenix Area HIM Consultant

2014 RPMS EHR HIM Impact & Coding

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Beta Test Lessons Learned (Special Thanks to Whiteriver & Gallup)

• Prepare Coding Staff Productivity Impact Inability to Edit Problem List Provider and Coder Impact – FAQ’s

• Workflow Considerations Policies and Procedures (How to complete a visit) .9999 ICD-9 Code (do not delete)

• HIM Monitoring Error Reports Increased Frequency Problem List Cleanup of Utmost Importance PRB Fix Uncoded PROBLEM FILE Diagnosis Review Allergies on Problem List Report

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HIM & Coding Considerations (Thank You Whiteriver and Gallup)

• Decrease in coding productivity CLEAN UP PROBLEM LIST Negative impacts downstream

• Aggressively monitor ERROR Reports to manage the increase in .9999 ICD Uncoded

• Family history can still be coded from TIU note although format is different

• Be aware of medico-legal impact of uncoded diagnoses (Fix Uncoded Diagnoses)

• DO NOT DELETE .9999 5

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HIM Supervisory Roles & Responsibilities in Preparing for RPMS EHR 2014

• Monitor Coding productivity • Train on RPMS EHR 2014 “Test” prior to “Go-

Live” • Standardize EHR GUI (Vuecentric) and TIU

Templates to support Clinical Documentation consistency

• Review and revise abbreviations • Educate Coding Staff on SNOMED Display in

IPL and Coding Queue 6

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HIM Roles & Responsibilities in Preparing for RPMS EHR 2014 CEHRT

• Clean up Problem List before conversion • Fix Uncoded Problem File Diagnoses • Identify CPT Superbills with ICD Associations to be

Disassociated • Export custom Pick Lists before conversion • Review Pick List needs • Review Configuration & Test EHR GUI (Vuecentric) Template

on RPMS EHR Test • Review & Revise Pharmacy Refill process for assigning POV • Review Nursing Process for workflow and Clinical

Documentation (eg Immunizations) 7

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What is SNOMED CT®?

Systematized NOmenclature of MEDicine Clinical Terms (SNOMED CT®) is a comprehensive, multilingual clinical terminology that provides clinical content and expressivity for clinical documentation.

Clinician friendly language to document clinical impressions, findings, and diagnoses.

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Why the Change to SNOMED CT®?

• 2014 Certified EHR requires: • SNOMED CT® for problem list • Longitudinal problem-focused documentation

including goals, care plans, and visit instructions • SNOMED CT® for much of the data used in Clinical

Quality Measures • Transition to ICD-10 - our goals are to:

• Stabilize the user interface in advance of ICD-10 changes

• Improve clinical documentation of problems and encounter diagnoses to support ICD-10 coding

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SNOMED CT® in the RPMS EHR

Where will you see SNOMED CT® ? • You will select SNOMED CT® terms instead of

ICD-9 or ICD-10 codes for diagnoses and conditions on the problem list, and clinical indications when ordering labs, medications, and consults.

• SNOMED CT® codes will also be stored in the background in other areas of the EHR.

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SNOMED CT® in the RPMS EHR

What does this mean for the clinical user? • The most significant change is a redesigned and

redefined problem list.

• The way problems are entered and managed and how POVs are selected has been changed.

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SNOMED CT® Related Maps Used in RPMS (cont.)

SNOMED CT® to ICD-9 – provided by CMS and delivered by NLM

• Use in EHR – for SNOMED problems and problems selected as POVs prior to ICD-10 transition

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SNOMED to ICD-9 Mapping Examples

When there is no mapping available OR when the closest ICD-9 code is more specific than the SNOMED, then the system will assign .9999 un-coded. The code assigned by coders will depend on the SNOMED term selected and the remainder of the visit documentation.

SNOMED Term

ICD-9 Storage of Mapped Codes

Sunburn of second degree

Sunburn of second degree 692.76 1:1 This is a 1:1 match so will store in the POV when selected.

Diabetic Nephropathy

Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled 250.00 Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere 583.81

1:1: This is a 1:1 match so will store both ICD-9 codes. When problem is selected as POV, 2 POVs will store.

Ganglion of the wrist

Ganglion of joint 727.41

Narrow to Broad: Closest ICD-9 code is less specific than the SNOMED. This will store in POV when selected.

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Mappings to ICD

Mappings are an integral part of the design of the Integrated Problem List and how SNOMED CT® will assist IHS with the transition to ICD-10.

These mappings automate, only when appropriate, assignment of ICD codes.

Mappings are transparent to the user. They are visible when selecting a SNOMED, on the problem list, visit diagnosis, and clinical indications.

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Assigning ICD Codes through EHR and Coding through PCC Coding Queue

• Provider selects SNOMED CT Problem and assigns as Purpose of Visit (POV) or Encounter Diagnosis

• Provider enters Provider Text for visit from POV Dialog (Optional)

• Coder reviews provider narrative, qualifier, and encounter notes.

• Coder accepts or changes mapped codes • Coder assigns ICD Codes to uncoded entries and adds

any additional codes supported by the Clinical Documentation

• Note: After conversion to ICD-10 an additional “Map advice” is passed through PCC to assist with ICD-10 transition

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Why Can’t I Edit Provider Narrative

• Provider narrative is stored as the SNOMED description ID (numeric value corresponding to the term the provider selected)

• Provider Text field is limited to 60 characters) and delimited by an “|”

• Narrative is a standard term stored as a numeric value and therefore it not editable by data entry/coding.

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Why Can’t I Edit Provider Narrative

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Format: SNOMED CT® term| provider text

Example: Hyperlipidemia| uncontrolled

Standard Term

Clinician Free Text

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Unmapped ICD Codes on Problem List • Problem List = SNOMED Codes (unable to assign ICD

Code to .9999) • POV = ICD Codes • Mappings to ICD are based on the specific SNOMED term • Final assigned ICD Codes for POV are based upon the

entire encounter documentation • When ICD Code is assigned for POV the Problem List

WILL NOT change (This is intentional) • Note: Fix Uncoded Problem File Diagnoses PRIOR to

conversion • Note: Provider is unable to take action on uncoded

Problem on Problem List

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Provider Narrative Abbreviations • Imbedded within SNOMED Term if to the left of “|”

and Coder is unable to edit • A future SNOMED CT update removes these

abbreviations • Train and encourage provides to select synonyms

without abbreviations

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Two or More POVs with One Provider Narrative

• SNOMED Terms may require two or more ICD Codes to define the condition

• Example: Diabetic Nephropathy 250 .40 describes the Diabetes 583.81 describes the Nephropathy V58.67 describes the Insulin Use

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RPMS EHR 2014 Conversion Contingency Plans

• Provider access to “Shadow Server” during conversion for viewing Patient Health Information

• Contingency Plan drill for paper workflow process, data entry, and scanning

• PCC Encounter Form training & availability • Inpatient Packet training & availability • PCC Data Entry for data elements • Scan PCC forms via Vista Imaging • Please DO NOT make providers duplicate note

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Hands-On Exercise RPMS EHR 2014 Preparation

• Use “PRB Fix Uncoded PROBLEM File Diagnoses” Menu to assign most appropriate ICD Code for available Narrative

• Use “POV Fix Uncoded PURPOSE OF VISIT Diagnoses” Menu to assign most appropriate ICD Code for available Narrative

• Generate PLAL Report “Allergies on Problem List” and examine appropriateness of those Allergies documented on Problem List

• Generate PCC Error Report and examine for “Uncoded Diagnoses”

• Compare and contrast HIM Monitoring Reports (see spreadsheet) for RPMS EHR 2014 CEHRT conversion

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Questions and Discussion

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Prepared by Susan Richards, MSN RPMS EHR Federal Lead

2014 RPMS EHR Software Changes Impacting HIM Coding

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Software Changes

• Many software changes were required for Meaningful Use 2014

• Some of the changes in functionality are temporary and will be restored in EHRp14 and EHRp15 DRAFT

Problem Management Change Description Comments Problems are now encoded in SNOMED • Immediate impact after

install • Impacts all users

• Users must update ICD-9 and uncoded problems to SNOMED prior to editing or using as POV

• Consider engaging all clinicians (nursing, pharmacy, etc.) in conversion effort

Clean up problem lists prior to deployment • Remove duplicates • Remove inappropriate

problems • Code uncoded when

possible

Care Planning can be documented • Optional functionality

User may choose to add goals, care plan and visit instructions

• Does not need to be used right away and is optional.

• May better support existing workflows that are using TIU or other workarounds to capture this info

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Problem Management Change Description Comments Priority is not visible on Problem List display • Immediate impact after

install • Impacts all users • Temporary issue

User may not sort display by priority

Restored in EHRp14

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POV Assignment Change Description Comments POV assignment from SNOMED encoded problems on Problem List only • Immediate impact after

install • Impacts all users who

assign POVs

Users must convert existing or add SNOMED encoded problem then select as POV.

• Can use SNOMED POV selection tool to select multiple problems.

Can no longer add POV from Historical Diagnosis component

View only component now • Future development to add back functionality is being considered

Can no longer add POV from pick list.

Pick list • Future development to add back functionality is being considered DRAFT

CPT Superbill Change Description Comments No longer can create diagnosis associations to store as POV • Immediate impact after

install • Impacts all users who

assign POVs particularly Nursing for immunization entry

• Temporary issue

• Superbill association does not support POV assignment

• Restored in EHRp14

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Pick Lists Change Description Comments Pick lists are used to populate Problems not POV’s • Immediate impact after

install • Impacts all users who

add/update/edit problems

Users may access pick lists from main problem screen and add/edit dialogs

Pick lists cannot be configured to display for certain users, clinics, disciplines • Immediate impact after

install

• The configuration tools are present but will not be honored until EHRp14.

• CACs should be judicious in importing/creating pick lists and use creative naming conventions for ease of use until EHRp14

Restored in EHRp14

Pick list configuration enhanced • Optional functionality

• Pick lists can be imported and edited

• Pick List items may be defaulted to specific status saving user clicks

Encourage engagement of clinical staff in selecting and editing pick lists

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Family History

Change Description Comments Family History conditions are added as SNOMED. Existing entries should be transitioned to SNOMED. • Immediate impact after

install • Impacts all users who use

Family History.

Transition of existing data can be done over time

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TIU Business Rules for Expected Cosigners

Change Description Comments TIU no longer honors any business rule that allows editing of a signed TIU note. Restricts any user except Privacy Act Officers and Chief MIS to amend documents. Result: Expected co-signers can no longer edit notes even if the business rule is configured. • Immediate impact after install

This was a change from the VA software. IHS will adopt this change.

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Questions and Discussion

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Prepared by Dujanna Bisonnette, RHIT, CPC Phoenix Area HIM Consultant

2014 RPMS EHR CEHRT Integrated Problem List & HIM Coding Impact

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Integrated Problem List MU Required Features

• SNOMED CT® Problem List • Care Planning • Treatment Regimen elements for CQM

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Integrated Problem List

• Reverse Mapping tool to assist with updating Problem List from ICD-9 to SNOMED

• Mapping to ICD-9 without user intervention • Data entry can still adjust coding when necessary and

if un-coded after selected for POV • POV selection from Problem List • POV selection dialog • Patient Ed documentation • Expanded statuses • Nationally vetted pick lists

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Integrated Problem List Get SCT Reverse Mapping Tool

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Integrated Problem List POV Selection Tool with Options for Additional

Care Planning and Patient Education Documentation

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Integrated Problem List Care Planning and Patient Education

Documentation

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Integrated Problem List Pick List Examples

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MU2 Data Captured by IPL Feature Required for

Performance Measure? Meets MU requirement

Problems: SNOMED CT® encoded

No MU2 rule, CQM data capture

POV selected from problem: SNOMED CT® passed to V POV

No CQM data capture

Goal Notes No MU2 rule, displays on CCDA

Care Plan Notes No MU2 rule, displays on CCDA

Visit Instructions No MU2 rule, displays on CCDA (CS)

Tx/Regiment/Followup No CQM data capture

Patient Education No CQM date capture, CCDA

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Family History

SNOMED CT for Family History Conditions

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Family History

Ability to document actual age of onset for documented conditions. Ability to note “approximate” for age of onset.

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Smoking Status

SNOMED CT® encoded Two new statuses

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Infant Feeding

• SNOMED CT® encoded feeding choices • Added secondary fluids if not exclusively

breast or formula fed

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Hands-on Exercise IPL and Coding Queue

• Select POV from IPL • Find Problem with .9999 on Problem List and

attempt to Remove • Use “Get SCT” Reverse Mapping Tool to map ICD to

SNOMED • Use Picklist to update IPL and POV • Enter “Provider Narratives” for POV • Document Status • Document Care Plan, Patient Goals, and Visit

Instructions

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Hands-on Exercise Miscellaneous Documentation

• Update Family History • Update Infant Feeding (Breast and Secondary

Fluids) • Select SNOMED CT for “Immunization Due” • Use CPT Superbill Tab to document CPT Code

for appropriate immunization via CPT Immunization Superbill with Associations Examine for ICD Association

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Hands-on Exercise PCC Coding Queue

• Examine Entire Documentation through PCC Coding Queue

• Code any and all POVs containing .9999 ICD Code

• Examine POV Provider Narrative and attempt to Edit

• Examine Problem List and attempt to assign an ICD Code

• Enter Family History through Coding Queue 48

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Questions and Discussion

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