Coding. Training Guide

Transcription

1 Cding (Specialty Hspital) Visin 4.3 (January 2013) Training Guide SurceMedical

2 VisinSH Cding Learning Center f Excellence Last change made: January Surce Medical Slutins, Inc. All Rights Reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. This dcument is intended fr use with Surce Medical Slutins licensed sftware. Visin is a registered trademark f Surce Medical Slutins, Inc. All ther prducts r cmpany names are used fr identificatin purpses nly and may be trademarks f their respective wners. CPT cdes, descriptins, and material nly are cpyright 2000 American Medical Assciatin (AMA). All rights reserved. N fee schedules, basic units, related values r related listings are included in CPT. AMA des nt directly r indirectly practice medicine r dispense medical services. AMA assumes n liability fr data cntained r nt cntained herein. The respnsibility fr the cntent f any "Natinal Crrect Cding Plicy" included in this prduct is with the Health Care Financing Administratin and n endrsement by the AMA is intended r shuld be implied. The AMA disclaims respnsibility fr any cnsequences r liabilities attributable t r related t any use, nn-use r interpretatin f infrmatin cntained in this prduct. The images, descriptins, and examples used in the dcumentatin are illustratins nly and nt meant t track ne patient thrughut the data entry prcess. All patients and patient data are fr illustrative purpses nly and d nt represent actual patients. Any reference t an actual persn is purely cincidental. Material in this publicatin is subject t change withut ntice. If yu detect any errrs r missins, r have cmments r suggestins fr changes, please the Learning Center f Excellence cntact at lce@surcemed.net. Surce Medical Slutins, Inc. Attn: Learning Center f Excellence 866 Nrth Main Street Ext. Wallingfrd, CT Fax Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 2

3 VisinSH Cding Table f Cntents Table f Cntents... 3 Visin Basics... 4 Lgging In... 4 System Wide Features... 5 Cding... 6 The Cding Windw... 7 Patient Selectin Header... 8 Diagnsis Tab... 9 Sample Wrkflw Prcedure Cding Tab Sample Wrkflw Charge Review Sample Wrkflw Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 3

4 VisinSH Cding Visin Basics Befre we begin, there are a few basics that shuld be reviewed abut the Visin sftware. Understanding these basic features will help yu better understand the mre cmplex features f the system. Lgging In Lgging int Visin requires a Username and Passwrd. After duble clicking n the Visin icn, yu will see the abve screen where yur persnal Username and Passwrd are entered. After entering bth the Username and Passwrd, click Lg in. Keep in mind, the Username and Passwrd are case sensitive and the system may require a change t the Passwrd n a peridic basis. Depending n yur facility s settings, the system may r may nt allw the same passwrd t be used again. Be aware that if the Username and/r Passwrd are repeatedly entered incrrectly r if a user has exceeded the time span fr system inactivity, the accunt will becme lcked and will need t be unlcked by the system s administratr. The number f attempts a user will have when entering a passwrd and the time span fr inactivity are determined by the facility s settings Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 4

5 VisinSH Cding System Wide Features Arrw 1: The first arrw at the tp pints t the sftware header, which displays the Surce Medical sftware that yu are currently using. Yu will als find the designated fur letter supprt cde fr yur facility. Fr example if yur surgery center was System Test Ambulatry Surgery Center, yu may see n yur tp rw Visin TASC. Yu will need this fur letter supprt cde whenever yu cntact the Visin Supprt Team. Arrw 2: The secnd arrw pints t the tlbar that list all f the general categries f the Visin system. By left clicking n any f these tlbar headers, yu will see a list f specific mdules in the system yu can pen. Fr example, if yu were t left click n the Financial tlbar header yu wuld find links t mdules such as Charge Review r Payments & Adjustments. Arrw 3: The third arrw pints twards the picture icns that are direct links t the specific mdules in the Visin system. These are quick and easy ways t get t these mdules if yu knw exactly where yu want t g. Fr example, instead f left clicking n the Financial tlbar fllwed by left clicking Charge Review, yu may simply left click n the Charge icn. Nt all mdules are accessible frm the picture icns. Arrw 4: The furth arrw pints t the Visin Managers. Left clicking n any f the given managers will pen that manager, which will have a number f picture icns. Like the picture icns frm Arrw 3, these icns are direct links t the specific mdules. Arrw 5: The fifth arrw pints t the Open Windws. In the abve screen, yu will see that there are currently n pen windws. As yu pen different mdules in the system, a link t that pen mdule will appear in the Open Windws bx. Always be aware f what windws yu have pened s that yu can avid ptentially duplicating yur wrk Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 5

6 VisinSH Cding Cding This dcument cvers the prcess f cding visits manually in Visin. If an interface is being utilized t attach apprpriate cdes t visits, the infrmatin in this guide can be used t understand where the infrmatin ppulates, hw t review that infrmatin and, if necessary, make crrectins. The Cding windw is accessed by selecting the EHR frm the Managers list n the left f the Visin main windw. Left-click t select the Cding icn lcated at the bttm left f the pictures icns t pen the cding windw Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 6

7 VisinSH Cding The Cding Windw The Cding windw is put tgether with fur main cmpnents. This windw facilitates cding f ICD-9 diagnsis and prcedure cdes, CPT cdes and CPT Mdifiers. 1 Patient Selectin Header This is where a patient s visit is selected fr cding. 2 Diagnsis This tab (pictured) is used t attach apprpriate diagnsis cdes t the patient visit. 3 Prcedure Cding This tab is used t attach prcedure cdes t the patient visit. 4 Charge Review This tab is used t pst charges and attach apprpriate CPT cdes and mdifiers t already psted charges as needed Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 7

8 VisinSH Cding Patient Selectin Header The Patient Selectin Header is used t select a patient visit fr cding and includes infrmatin used t cnfirm that the crrect patient and visit have been selected prir t entering cding infrmatin. Name Search fr a patient using any f these ptins: Name Enter the patient partial r cmplete last name, t include their first name in the search, insert a cma. T search exclusively by a patient s first name, use a cma as the first character fllwed by the name. Medical Recrd Number Enter the patient s MRN, if the number has leading zers, thse digits need nt be included in the search Date f Birth Enter the patient s DOB in the frmat MM/DD/YYYY. The slashes must be included t distinguish this number frm the MRN. Scial Security Number Enter the patient s SSN in the frmat XXX-XX-XXXX. The dashes must be included t distinguish this number frm the MRN. Visit If the patient has multiple visits, select the ne that requires entry f cding infrmatin. Case When cding prcedure infrmatin, select the scheduled case the prcedures were perfrmed during. If the prcedure was perfrmed independent f a scheduled case, this selectin can be ignred. Read Only Fields The remaining fields in this sectin are nt editable and are used t cnfirm that the crrect patient and visit are being cded Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 8

9 VisinSH Cding Diagnsis Tab The Diagnsis Tab is used t attach apprpriate diagnsis cdes t the patient visit. Admitting DX Enter the patient s admitting diagnsis cde. DX E-Cdes The cdes entered in these fields appear n the claim frm in the spaces designated fr E-Cdes. These are nt required as they are situatinal. If n E-Cdes apply t this visit, skip these spaces. If mre than three are required, select the Addl. E-Cdes buttn. The drp dwn menus t the right f the diagnsis cde selectin cntain the POA indicatrs: Y Yes N N U Unknwn W Clinically Undetermined 1 Unreprted Visit Reasn(s) The cdes entered in these fields appear n the claim frm in the spaces designated fr Visit Reasns. These are nt required as they are situatinal. If n Visit Reasns apply t this visit, skip these spaces. Visit DRG Enter the Visit DRG in this space. The mst effective way t search fr cdes in this list is t enter the numeric cde directly. NOTE: The mst effective means f searching fr a diagnsis cde is t enter the ICD-9 Cde (including the decimal) rather than by descriptin. When searching fr cdes that include letters, make sure t enter the letters in a capital frmat as the search is case sensitive Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 9

10 VisinSH Cding Visit DXs POA Indicatrs All ther cdes nt attached using the previus fields are attached in this sectin. Scheduled/Perfrmed/All Filters the list f diagnsis cdes. Scheduled cdes are attached t the visit when a case is scheduled. These t nt appear n a claim unless they are selected and marked as perfrmed. Any cdes added frm this windw directly are autmatically designated as perfrmed. Add Left-Click n this buttn t pen up the fields in the bttm f this bx fr selectin. Update Select a cde frm the list and left-click this buttn t display the cde in the fields at the bttm f the bx t make changes. Remve Select a cde frm the list and left-click this buttn t remve it frm the list. DX Search fr a cde t attach t the visit. See nte n the previus page fr tips n searching this list. POA Indicatr This field, t the right f the DX selectin is nt specifically labeled, but cntains the POA indicatrs (as listed n the previus page) that can be assciated with that cde. Perfrmed This bx is checked by default and indicates that this cde is valid and shuld appear n the claim. Save Dx Left-Click n this buttn t save the current DX and POA infrmatin t the grid in the center f the bx. Cancel Left-Click n this buttn t discard unsaved infrmatin in the DX and POA bxes Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 10

11 VisinSH Cding Sample Wrkflw 1. Enter Admitting DX 2. Click Add in the Visit DXs bx 3. Enter DX 4. Select Apprpriate POA 2013 Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 11

12 VisinSH Cding 5. Click Save Dx 6. Repeat Steps 2-5 until all cdes have been added. 7. If needed, rerder DX cdes by hlding the left muse buttn t drag a diagnsis cde t the apprpriate psitin in the list and then release the left muse buttn. 8. Cding remarks can be added by typing in the Remarks bx. 9. Left-Click in the bx labeled Cding Cmplete t indicate that this step is cmplete and is ready fr billing. If the visit requires cding t be perfrmed fr prcedures, d nt ppulate this check until that step has als been cmpleted. 10. Click Save r Clear t cnfirm r discard unsaved infrmatin. These functins apply t infrmatin entered utside the Visit DX POA Indicatrs bx as that infrmatin is saved as it is entered Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 12

13 VisinSH Cding Prcedure Cding Tab The Prcedure Cding tab is used t attach bth CPT and ICD-9 prcedure cdes t the patient visit. Prcedures (Grid) The Prcedures grid shws the CPT cdes assciated with the visit. The specific cntents f the grid are cntrlled by the Scheduled, Perfrmed, and All radi buttns psitined at the tp f the grid. Prcedures can be cded at the visit level and at the case level fr reprting purpses. When a Case is selected (as shwn abve) in the Patient Selectin Header, the prcedures listed are assciated with that specific case within the visit as are any additinal CPTs entered n the tab. If n Case is selected, the prcedures listed are assciated with the visit rather than with the specific case as are any additinal CPTS entered n the tab. Add/Update/Remve Left-Click the Add buttn t enter a new CPT cde t the Prcedures list (this is nt always a necessary step as the Prcedure bx is typically available fr selectin already). Left-Click the Update buttn t change infrmatin assciated with the currently selected CPT cde in the Prcedures list (this can als be accmplished by duble-clicking n the cde). Left-Click the Remve buttn t remve the currently selected CPT cde frm the Prcedures list. Prcedure Search fr and select the perfrmed prcedure frm the list. The prcedure can be searched fr using the CPT cde r descriptin. This is a read-nly field when updating an item frm the Prcedures list Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 13

14 VisinSH Cding CPT Cde This is a read-nly field that identifies the CPT cde the prcedure is linked t. Because billing infrmatin is cntrlled by the CDM in VisinSH and nt the prcedure library, this link is nt required. PI Payment Indicatr as with the CPT Cde bx, this is read nly and cnveys a link that has n cnsequence in VisinSH Perfrmed Check this bx t indicate that this is a prcedure that was perfrmed during the case r visit. Perfrmed Order Enter the rder in which the cdes shuld be displayed (enter 1 fr the first prcedure cded, 2 fr the secnd, etc.) Scheduled/Billed/Active These three bxes are read-nly and are cntrlled by Visin t expse the prcedure s system status. Descriptin This is a read-nly field that displays the descriptin assciated with the selected CPT cde as entered in the Prcedures library. Start/End Date This infrmatin can be entered as needed, but is nt required. Surgen/Assistant The Surgen and Assistant surgen are ppulated autmatically based n infrmatin entered in scheduling and the patient chart, but may be mdified as needed. Bdy Side Bdy side infrmatin is ppulated frm scheduling as a reference pint and is read-nly. CPT Mdifiers Enter any mdifiers assciated with the prcedure being cded. When searching the mdifiers list, remember that the search is case sensitive: entering rt des nt result in a successful search fr RT, the search must be entered in all caps. Prcedure ICD Enter the ICD-9 Prcedure cde(s) that crrelate t the prcedure being entered. This search is mst effective when the cde, rather than the descriptin is entered directly including the decimal. Save/Clear - Click Save r Clear t cnfirm r discard unsaved infrmatin Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 14

15 VisinSH Cding Sample Wrkflw 1. If psting a cde at t a specific case, make the apprpriate selectin frm the Case menu. If psting a cde nt affiliated with a specific case, ensure this selectin is blank t pst t the visit. 2. Review any scheduled cdes in the Prcedures list. a. If the scheduled cde is the crrect cde, duble click the cde and skip t step 4. b. If the scheduled cde is nt the crrect cde, cntinue t step Select the apprpriate prcedure cde frm the Prcedure menu. 4. Click the Perfrmed checkbx Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 15

16 VisinSH Cding 5. Enter the apprpriate charge rder number in the Perfrmed Order bx. 6. Cnfirm the Surgen and Assistant. 7. Enter any CPT Mdifiers. 8. Enter any ICD-9 Prcedure Cdes. 9. Click Save Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 16

17 VisinSH Cding 10. Repeat steps 3-9 until all cdes are psted. 11. If psting prcedures finalizes the cding prcess, return t the Diagnsis tab and click the Cding Cmplete checkbx Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 17

18 VisinSH Cding Charge Review The Charge Review tab is used t review psted charges and attach apprpriate CPT cdes and mdifiers as needed. A functin t add charges is als available if wrkflw requires cders t d this. The charge psting functin prvided here is much mre basic than the ne used by the business ffice t review and prepare charges fr claim presentatin and in particular des nt disclse the charge amunt being psted. Filters Chse HCPCS/CPT Only t display nly thse charges that have a CPT cde attached t them already. Select All Charges t see every charge assciated with the visit regardless f whether they have a cde attached already. Grid Display Mst f the grid is read-nly. The nly editable clumns are the HCPCS/CPT and Md #1-#4. Click in the grid space t reveal a drp dwn menu that can be searched by typing r expanded by clicking n the dwn arrw t select a cde Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 18

19 VisinSH Cding Add Charges Left-Click the Add Charges buttn t pen a windw that allws selectin f specific charge types t the patient visit. Visit/Case Select whether the charge is applied just t the visit r t a specific case that ccurred during the visit. If case is selected, chse the apprpriate event frm the Case menu. Charge Select the charge t pst frm the list. Only resurce and rder charges are available. Prcedure charges are nly prduced by cding the apprpriate items n the Prcedure Cding tab. Anesthesia and Rm charges can nly be manually attached frm the Add Charges tab in the Charge Review windw used by the business ffice t review and prepare charges fr claim presentatin. Descriptin This field is read-nly and displays the charge descriptin as it appears in the CDM. Units Enter the number f units t charge. CPT Mdifiers Enter the mdifier(s) that apply t this charge. Save & New/Save & Clse/Cancel Left-Click Save & New t cnfirm the data entered and leave the windw pen t pst additinal charges. Left-Click Save & Clse t cnfirm the data entered and clse the windw. Left-Click Cancel t discard the data entered and clse the windw. Sample Wrkflw The functins n the Charge Review tab are situatinal and s there is n representative wrkflw t demnstrate Surce Medical Slutins, Inc. All rights reserved. N part f these materials may be reprduced r transmitted in any frm r by any means, electrnic r mechanical, including phtcpy, recrding r any infrmatin strage and retrieval system, withut the express permissin f Surce Medical Slutins, Inc. Page 19