2010 UBO/UBU Conference Title: Enhancing Clinical Documentation with the Tri-Service Workflow (COMPASS) Session: R

Overview How the Tri-Service Workflow assists with documentation requirements Why Coders are integral members of the Workflow team 2

Coding E&M coding is complex Providers need tools to quickly and accurately determine E&M coding AHLTA coding calculator is unreliable and inaccurate The Tri-Service Workflow coding method delivers simplified tools for accurate, rapid E&M coding But it’s not enough… 3

Tri-Service Workflow Focus Established patients: focus on history & MDM History – Workflow is built to have a clinically appropriate detailed history – Workflow delivers : “CC/ 4:2:1” = detailed Chief complaint 4 (5) bullets for HPI “duration, severity, pain rating, associated symptom and modifying factors” 2 Review of Systems (ROS), 1 bullet from 2 systems – Occupational and neurological All Elements from PMHx, PSHx, Family Hx, Medications 4

Documentation Code conditions that impact the encounter – Hypertension – Diabetes Mellitus – Asthma – Congestive Heart Failure – Parkinson’s Disease – COPD – Emphysema 5

A “Yes” response to any one of the items below gives a * (Est Pt)** 3 Established Problems Stable or Improving (addressed in Subj) 1 Established Problem + 1 Established Problem Worsening (both addressed in Subj) 1 New Problem (not self limited or minor, new to the provider) + Rx (not OTC med) Review and Summation of Old Note + Rx (not OTC med) Order Rad/ECG + Independent Review + Rx (not OTC med) *Three assumptions: 1. Detailed History has been accomplished (CC:4:2:1) 2. This is an established patient 3. CODING IS BASED UPON DOCUMENTATION IN THE NOTE (e.g., new problem must be stated as such in note, etc.) **If the answer is “no” to all questions above, the code is a UNLESS the patient has 1. Only one problem which is self-limited/established stable AND 2. Minimal data review or minimal management (rest/Band-Aids, salt water gargles, etc.)- then it is a Tri-Service Workflow Simplified Coding NOTE: Clinical necessity determines your work. Do not work toward a code.

Accurate Coding Document smarter – Support staff focuses on past medical history items, ROS and Joint Commission/HSI – Provider focuses on HPI (the story), PE, A/P 7

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When to Trust/Not Trust AHLTA Override coding calculator – Will often have to override for Est and New patients You can trust AHLTA for – Coding based on time – Greater than 50% of encounter with counseling & coordination of care – time-based coding Time spent counseling and coordination of care Total time spent What was counseling about Why the extra time was needed – Coding Preventive Health Visits 11

To Override AHLTA’s Coding Calculator From the Disposition screen, select the SELECTION tab Now highlight the code you want to assign to this encounter. Tobacco Cessation Counseling (3-10 min)0.24 RVU99406 (Disposition E&M) Tobacco Cessation Counseling (10+ min)0.50 RVU (Disposition E&M) Cerumen Removal requires provider skill0.61 RVU69210 Skin Tag Removal up to 15 lesion0.79 RVU11200 Shave Skin Lesion (site & length required)1.05 RVU I&D Abscess1.19 RVU10060 Bx, Skin, Tiss/Mucous Membr0.81 RVU11100 IV Fluid, 1 hour for hydration0.17 RVU96360 ECG w/interpretation and report0.17 RVU93000 Cryosurgery of Skin up to 14 lesions0.67 RVU17110 Screening Pap Obtain0.37 RVUQ0091 (HCPCS) IM/SC Injection0.17 RVU Digital Rectal Exam (annual)0.17 RVUS0605 (HCPCS) Foot Incision FB in Foot (splinter)1.98 RVU28190 Drainage finger abscess (felon)2.21 RVU26011 Surgery penile lesion destruction (cryosurgery)1.26 RVU54050 Ablation vulvar lesion (cryosurgery)1.55 RVU56501 Skin debridement0.80 RVU11042 Closed tx of phalanx fx1.12 RVU28510 Closed tx of great toe1.12 RVU28490 Incision & removal of foreign body, subcutaneous, simple1.23 RVU10120 Excision of nail/matrix, permanent2.40 RVU11750 Repair Superficial Wound (site & length req)1.38 RVU Drain/Inject Joint/Bursa (major joint)0.79 RVU20610 Removal of Sperm duct(s) Vasectomy3.32 RVU55250 (2009 CPT code) Updated 10 Nov 09 from: Sample Procedures with RVU’s 12

Tri-Service Workflow Coding Based upon and consistent with CMS 1997 coding guidelines Compliant with MHS Coding Guidance 13

Is This Gaming the System? No, provided all information documented is medically relevant to the encounter Follow MHS Coding Guidance Based upon but not identical to Center for Medicaid and Medicare (CMS) and American Medical Association (AMA) guidelines 14

Tools to Improve Coding BDQAS (AF Metrics) 1995 and 1997 E&M Documentation Guidelines – AHLTA based on ’97 DoD Coding Guidelines Service Audits AHLTA – Tri-Service Workflow AIM form and other workflow based AIM forms – Encounter Templates – Favorites List – Workflow 15

Coders/Auditors Are Vital Members of the Team 16

Why are Coders/Auditors are Integral to Workflow? You are the coding SME Extensive knowledge of all aspects of coding – Simplified coding only address the most common E&M scenarios – Providers need training on CPT and ICD-9 coding Onsite and in the trenches Coding instruction and feedback is most valuable to providers when it is combined with AHLTA training 17

Air Force Combined Audits and Training Members of workflow Audit/Training Team – Coders/Auditors – AHLTA trainers – AFMSA/SG6 Workflow Division team members Remote charts reviews accomplished with team Feedback given to providers and SGH Training can be targeted to specific coding deficiencies Helpful AHLTA tools can be taught by AHLTA trainers in conjunction with the Auditor/Trainer to address the coding deficiencies YOU ARE KEY MEMBERS OF THIS TEAM! 18

Workflow Research Results JC/HSI 19

Workflow Research Results RVUs RVU per encounter Provider Entered Corrected Pre Compass Staff Post Compass Staff Provider Entered Corrected Pre Compass Intern Post Compass Intern

Workflow Research Results Coding Accuracy 21

Summary The Tri-Service Workflow Simplified Coding is a 25% solution Coders/Auditors are vital members to the workflow and address the other 75% of coding areas 22

Questions 23