Admission/Discharge/Transfer (ADT), Coding & Error Resolution RPMS EHR Inpatient

Admission/Discharge/Transfer (ADT) Pre-implementation Check-List PIMS ADT User’s Manual Jan 2009 ww.ihs.gov PCC Supervisor’s Manual www.ihs.gov IHS Chapter 3, HIM Manual www.ihs.gov Present on Admission Site Parameters (PCC)

Things to Consider… Admit/Discharge orders (Date/Time) Setup ADT Files (System Definition Menu) Treating Specialty (OB, NB, GM, PEDS, OBS) Room-Bed Ward Switch Bed (SWB) Ward Transfer (WTX) Attending physician (Change Provider when there is an order) PCH Provider Change

Things to Consider cont’d… Against Medical Advice (AMA), Absent without Leave (AWOL), Patient on PASS Discharge from Observation to Admit to acute care (time must be 1 minute after discharge from observation) Intra-facility transfers (ward, treating specialty) There must be an order from the attending physician to transfer from one ward to another, and from one provider to another provider (SWP)

Things to Consider cont’d… Discharge Time of Discharge (discharge orders and nursing discharge) Correct discharge treating specialty (Mnemonic: IP) Transfer to an IHS or non-IHS facility (build your own list) Admission/Discharge Type/Source IHS UB-92 It is important to admit, discharge, and transfer in a timely manner!

Discharge Summary PCC Inpatient Supplemental & Discharge F/U Record, IHS-485 (not required) D/C Summary Tab v. Dictated DS Discharge Summary template Present on Admission (POA) Parameters Acute Care v. Critical Access Hospital POA (may be added to the template) Importing data objects into the template (med list, labs, patient education codes)

POA Parameters UPDATE PCC DATA ENTRY PARAMETERS SITE NAME: DEMO HOSPITAL ************************************************************************ UPDATE DEFAULT PARAMETERS (press enter): FORMS TRACKING? (Y/N) Y UPDATE DISPLAY PARAMETERS (press enter): ASK OUTSIDE LOCATION? (Y/N) Y Prompt for VISIT CREATION? (Y/N) Y ASK PROVIDER EVENT TIME? (Y/N) PROMPT FOR MODIFIERS WITH CPT ENTRY? YES PROMPT FOR MODIFIER ON POV? N ASK WALK-IN/APPT FOR CLINIC? (Y/N) Y TYPE OF PROCEDURE CODING: ICD OPERATION CODING Require Present on Admission (POA) for Hospital Stays? ? Choose from: 1 DO NOT REQUIRE POA - CRITICAL ACCESS HOSPITAL 0 REQUIRE POA

Present on Admission Enter PURPOSE of VISIT: HTN 401.9 (HYPERTENSION NOS) UNSPECIFIED ESSENTIAL HYPERTENSION OK? Y// PRESENT ON ADMISSION?: Choose from: Y YES N NO U UNKNOWN W CLINICALLY UNDETERMINED 1 UNREPORTED/NOT USED (Exempt Codes) PRESENT ON ADMISSION?: Y YES

Inpatient A Sheet 25 Admitting Diagnosis Insurance Coverage DIABETES II/UNSPEC NOT UNCONTR (250.00 -------------------------------------------------------------------------------- 26 ICD9 27 POA 28 Established DX 250.00 X DIABETES MELLITUS CONTROLLED 401.9 HYPERTENSION 496. CHR OBSTRUCTIVE PULMONARY DISEASE

Coding Use of Historical diagnoses (pertinent to the inpatient stay) Adding a Diagnosis E&M codes Initial Subsequent Days (Daily) Discharge Management Observation Present on Admission Documentation (Coders enter codes/POA Indicators in ADT) Final A Sheet vs. A Sheet worksheet Inpatient Deficiencies

In-Hospital Visits Description A patient seen by a consultant while in the hospital, e.g., receiving physical therapy treatment during a Hospitalization. Link In-Hospital Visits to Hospitalizations (INP) AUT Link In-Hospital Visits to Hospitalizations MAN Manually Link In-Hospital to H Visit

TIU and ADT Reports TIU SSD option should be used to monitor and track incomplete documents Unsigned, Signed, by provider, Date range, Progress Notes, Discharge Summaries ADT Reports Menu (RM) Current Inpatient Listings Provider's Incomplete Charts Incomplete Chart Reports (ICR) Listing of Coded A Sheets Operators' Inpatient List Incomplete Chart Statistics (ICS) Inpatient Coding Status Report Incomplete/Delinquent Statistics by Provider

Daily/Monthly Census Admissions & Discharges Sheet (ADS) Monthly Census (M202) (CEN) Yearly Census (Y202) (CEN)

Correcting Errors Changing Note Title Retracting a Note (Justification documentation) Reassign Note

Questions?