From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:The Coder’s Role with AHLTA Date:22 March 2007 Time:

2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives To assist the coding professional gain a better understanding of the concept of the AHLTA automated coding module as well as educating and training the provider in its appropriate application To help coders and auditors understand the AHLTA application in the A/P and Disposition screens where the automated coding of the encounter takes place Help providers improve documentation and understand the advantages and limitations of the application To be most effective, coders must learn to educate providers by understanding the way AHLTA “thinks” and show them how to work within the AHLTA system to apply, override, or accept the auto-assigned E&M code

2007 UBO/UBU Conference From Registration to Accounts Receivable 3 AHLTA & Coding AHLTA provides “point-of-care coding support” Use of templates and/or AIM forms will ensure the most accurate calculated E&M in AHLTA – Free text documentation and/or scanning of information into an encounter will require the provider to manually over-ride the calculated E&M to avoid under-coding or misapplied codes Codes are linked to all procedures and diagnoses in AHLTA

2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Coding Calculations E&M = Documented HPI + Exam + Diagnosis + Assessment + Patient Status + Service type Misapplied documentation placed in the incorrect location in the module will not calculate the correct E&M Free text does not “count” toward the correct E&M level AHLTA allows visualization of E&M calculations in the Disposition module before provider signs the encounter Most coding professionals are not familiar with the Disposition section in AHLTA because they do not have a provider status assigned AHLTA does not apply or prompt for appropriate modifiers, bundling or unbundling concepts or patient status (i.e., new vs. established patient)

2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Diagnosis Tab in the AP Module The A/P Module Inclusion of common diagnoses and procedures in your templates is preferred. However, you may use Add to Favorite List for common or hard to find diagnoses and procedures that aren’t in your templates Add diagnoses to personal favorite list by highlighting the code at left and clicking the button below

2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Procedure Tab in the AP Module. Use to code for procedural services performed by you or your staff. Use the “ORDER” tabs for procedures to be performed in other departments of the hospital, i.e., labs and rads Some codes, such as Pap collection and injectable meds (B12, Bicillin), must be searched under HCPCS May add procedures to Favorites List as well The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 7 The Disposition Module Your calculated E&M is derived from your template documentation, the diagnosis, patient status, service type, and exam type The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Notice what I have in the Vitals tab. At least 3 vitals need to be recorded to count as a “Bullet.” Also notice I addressed the tobacco and alcohol use. Even negatives count as social history These do not count toward the E&M The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Despite addressing the tobacco and alcohol history, it does not pick up in AHLTA. Therefore, no credit for these documentation elements is assigned by AHLTA. Also, there is no credit for the vital signs for calculation The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Medcin Tree Vital signs reviewed The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 11 No credit given for that term! The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Marks the terms of the vital signs that were done to receive credit The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 13 If the provider marks each individual vital sign that was done, credit will be given. It is not necessary to re-document the actual measurements The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 14 PMH Tab—Social History—Behavioral History— Alcohol and/or Tobacco The same method applies to Tobacco and Alcohol documentation The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Credit is then given The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 16 The Disposition Module Select whether your patient is new or established The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Use the Selection tab to code your visits manually Preventative Medicine and levels Click here for the drop-down list of E&M categories is selected here for procedure only visits (i.e., injection only, visit for colonoscopy, etc.), and Preventive Medicine Eval is selected for 9938X or 9939X The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 18 The Time Factor section is only used when >50% time is spent counseling or coordinating care. Do not use to artificially up-code the visit Use the Comments tab to open the free-text box to document the total visit time + time spent counseling and/or coordinating care, if not documented elsewhere on encounter. Also document details of counseling and/or coordination of care. This justifies increased coding value when legitimate. This function only works from the calculated coding function, and does not hold if you leave Disposition module and come back AHLTA will calculate the code based on time only when both boxes are checked The A/P Module

2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Summary If the coder can help the provide DOCUMENT well, AHLTA will code accurately If you don’t train to document well, your provider may lose RVUs or mistakenly over-code if they don’t understand E&M documentation guidelines If providers use alternative methods of input (free text, scanning, pasted documents) they will have to know how to code manually