© 2013 the mcgraw-hill companies, inc. all rights reserved. chapter 9 tests, procedures, and codes
TRANSCRIPT
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 9
Tests, Procedures, and Codes
© 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
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• American Medical Association (AMA)• Diagnosis Codes• Lab Analyte• Procedure Codes• Reference Labs• World Health Organization (WHO)
Chapter 9 Key Terms
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• 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
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LO 9.1 Ordering a Test
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• 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
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LO 9.2 SpringLabs and Reference Lab Results
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• 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
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• 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
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• 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
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LO 9.3 Processing and Charting Tests
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• 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
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• 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
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LO 9.4 Creating a Test Report
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• 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
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LO 9.5 Documenting, Activating, and Editing
Procedure Codes
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• 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
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• 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
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• 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
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• Codes are updated annually– Procedures must be updated to keep
reimbursement accurate
Editing a Procedure
LO 9.5
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LO 9.6 Documenting, Activating, and Editing
Diagnosis Codes
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• 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
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• 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
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• Codes are revised periodically
• Currently in 9th 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
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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
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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
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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
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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
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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
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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