1. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 9 Tests, Procedures, and Codes

2. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 9.1 Ordering a Test 9.2 SpringLabs and Reference Lab Results 9.3 Processing and Charting Tests 9.4 Creating a Test Report 9.5 Documenting, Activating, and Editing Procedure Codes 9.6 Documenting, Activating, and Editing Diagnosis Codes Chapter 9 Learning Outcomes

3. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. American Medical Association (AMA) Diagnosis Codes Lab Analyte Procedure Codes Reference Labs World Health Organization (WHO) Chapter 9 Key Terms

4. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Entire ICD-9 and CPT dictionaries as well as a comprehensive list of lab, imaging, and medical tests are installed in SpringCharts database – Limited activated list of the current year’s diagnosis and procedure codes and lab, imaging, and medical tests are installed in SpringCharts – Allows quick selection of codes common to practice Additional Dx codes, CPT codes, and tests can be activated from the dictionary files Overview

5. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.1 Ordering a Test

6. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Tests include: – Laboratory tests – Imaging tests – Medical tests Tests can be ordered from: – Patient’s Chart Screen – Office Visit Screen Ordered tests are stored in the Pending Tests area – Results can be entered manually or automatically Pending tests with results are sent to the Completed Tests area for physician viewing Tests that have been viewed by the physician are permanently filed in the patient’s chart in the care tree diagram Ordering a Test LO 9.1

7. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.2 SpringLabs and Reference Lab Results

8. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. SpringLabs is an optional lab interface – Receives lab results electronically from lab companies – Notifies users of newly received results by a LAB icon next to the user’s login name – Stores permanently imported lab results SpringLabs & Reference Lab Results LO 9.2

9. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Learns the way a practice prefers to receive results – Remembers the synonyms for automatic test matching Matches: – patient’s name – test name – test analyte Tests are reconciled to Pending Tests and results are sent to Patient’s Chart SpringLabs & Reference Lab Results LO 9.2

10. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Force Enter is used when SpringLabs does not recognize the Patient or Pending Test Delete removes a test from the Reference Lab list – Keeps a copy in the test repository SpringLabs & Reference Lab Results LO 9.2

11. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.3 Processing and Charting Tests

12. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Results must be entered manually when completed in the clinic and not processed automatically through SpringLab Results can be copied and pasted in from reports received electronically Add tech’s signature and facility to test result window Perform administrative functions from test window (Messages or ToDos) Processing and Charting Tests LO 9.3

13. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Abnormal results automatically highlighted for physician Physician views Completed test and stores in patient chart Automated Test Status Alerts in chart display pending or completed tests Processing and Charting Tests LO 9.3

14. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.4 Creating a Test Report

15. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Created for the patient and enables the provider to add problems and recommendations to the report Test Results cannot be changed once charted Test results appear in H&P reports and Examination reports Test Report LO 9.4

16. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.5 Documenting, Activating, and Editing Procedure Codes

17. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Procedures are selected from within the Office Visit Screen Choose from Previous Procedures window or Procedure category list Procedure categories are set up in the Administrator menu of SpringCharts server Documenting a Procedure LO 9.5

18. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. New procedures can be activated from CPT dictionary Procedural text can be added to code setup Procedure text will automatically populate OV note when the procedure is selected Creating a Procedure LO 9.5

19. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Creating an immunization procedure can automate the reporting process to registries ONC requires all ONC-certified EHR programs to have the ability to record specific details regarding immunization procedures: – vaccine code (CVX) – manufacturer code (MVX) – lot numbers – expiration dates Creating an Immunization Procedure LO 9.5

20. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Codes are updated annually – Procedures must be updated to keep reimbursement accurate Editing a Procedure LO 9.5

21. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.6 Documenting, Activating, and Editing Diagnosis Codes

22. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Diagnosis can only be selected within the OV note or main screen Added to the Assessment area of the SOAP note Documenting a Diagnosis LO 9.6

23. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Limited code set is activated, but all are installed Activate a new diagnosis by selecting New Diagnosis under the New menu on the Practice View screen Can Lookup a code from the ICD database Use Dx Brief Name for the description the clinic will use Creating a New Diagnosis LO 9.6

24. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Codes are revised periodically Currently in 9 th edition ICD-10 is planned for release in October 2014 – More robust and descriptive – First digit is always alpha – Twice as many categories – 3-7 characters in length – Around 68,000 codes Editing a Diagnosis LO 9.6

25. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.1 Describe how to order lab, imaging, and medical tests Tests are classified : – lab tests – imaging tests – medical tests All ordered tests are stored in the Pending Tests area of the EHR program When data is input to a pending test, it is then sent to the Completed Tests area of the program for the physician’s viewing Tests are ordered from within the OV screen or within the Patient Chart screen The printer icon in the OV note enables printing of an order form for ordered tests Chapter 9 Summary

26. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.2 Process Reference Lab results that are received electronically Importing lab results as structured data is an ONC MU criterion SpringLabs is electronic data interchange (EDI) – interfaces SpringCharts to lab companies across the Internet Imported lab results have to be manually matched to the patient, pending test, and lab items (analyte) to ensure accuracy Chapter 9 Summary

27. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.3 Process and chart tests manually Assessment or evaluation text is added to the imaging and medical pending test Structured data is added to the lab pending test In the Pending Tests and Completed Tests windows, the clinician can: – open the patient’s chart – send a message – create a ToDo Item – add a note The completed lab test highlights results outside the normal range to alert the physician Chapter 9 Summary

28. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.4 Create a test report ONC requires that patients have access to electronic copies of certain health information like test reports Test report is created from within the patient’s chart Test report can run utilizing any of the test results saved under the lab, imaging, or medical tests categories in the patient’s care tree Test report displays the test result along with a description of and the purpose for the test Chapter 9 Summary

29. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.5 Create, edit, and document procedures Comes with entire procedure dictionary, but only selected procedures are activated Procedures are documented in the OV note where additional notes can be added to the procedure Procedural text can be added to a new procedure and becomes part of the OV note when the procedure is selected ONC requires EHRs to report administered immunization procedures to local and national immunization registries An immunization procedure has many more fields to complete than a typical procedure code Chapter 9 Summary

30. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. LO 9.6 Create, edit, and document diagnoses Diagnosis codes: – developed, monitored, and copyrighted by the WHO – documented only in the OV screen Diagnosis notes can be added to the selected diagnosis, affecting only the OV note for this specific patient New diagnosis can be activated from the OV screen or the main Practice View screen Dx Brief Name field determines the text for which the practitioner will search when selecting a diagnosis in the OV screen In 1977, the United States adopted the ninth edition of the ICD codes and has now adopted the ICD-10 terms and codes ICD-10 compliance initially meant that all HIPAA-covered entities would successfully conduct healthcare transactions on or after October 1, 2014, using the ICD-10 diagnosis codes Chapter 9 Summary