AHLTA: Make AHLTA Work for You! Introducing the "Usability AIM

1. PRESENTATION ON AHLTA: How to make AHLTA work for you!Introducing the “Usability AIM”Possibly the only AIM you’ll ever need!Anthony Inae M.D.tony@inae.net March 24, 2008

2. Goals for the Presentation You will learn how to: 1. Document quickly, easily and effectively 2. Receive appropriate credit for what you do 3. Go home on time

3. Outline • Speed up Windows • Core Templates • How an E&M code is determined • How RVU’s are determined • The Usability AIM Form • Adding the Usability AIM Form to you’re my Favorites List

4. Speed up Windows Speed up Windows XP by turning off Visual Effects

5. Turn off Autosave and AutoPrint User Preferences • You can get to this options box by clicking “options” while in the SO module

6. Core Templates Keep Favorites List of Templates to a Minimum 2. **Well Visit Templates 3. Procedure Templates 4. The 80% Template Core Templates You Need, nothing more, nothing less… Items not on an AIM Form + A/P Items 1. Default Template (*list template) Ex. “Usability AIM” Form 5. Most commonly seen Diagnoses (several times per day) Templates (optional) Ex. Cold (URI) Template Delete or remove everything else * List template for S/O Medcin terms. Personal preference. AIM Form attached to default template takes longer to load. ** Ex. Well Woman (Pap), School, Flight, PHA and General Physicals, Pediatric Well Visits, etc…

7. How an E&M Code Is Determined Basics of an Outpatient Visit The visit is made up of 3 components: [1] Patient History • History of Present Illness (HPI) • Review of Systems (ROS) • Past Family Social History (PFSH) [2] Physical Examination [3] Medical Decision Making • Diagnosis/Management Risk • Complexity of Data • Problem Risk • Test Risk • Management Risk For Established Pts 2 of 3 components are required to meet the level for that visit. For New Pts All 3 are required

8. How RVU’s are Determined A provider’s RVUs are determined primarily by 2 components • Evaluation and Management Code (E&M) • Procedures (CPT and HCPCS codes)

9. Sample E&M RVU Numbers • New vs. Established (more points for new patients) • Primary Care and Family Practice are DIFFERENT clinics. • E&M Codes New/EST • 99212 (Prob Focused) 0.45/0.45 RVU • 99213 (Expanded Prob Focused) 0.88/0.67 RVU • 99214 (Moderate Complexity) 1.34/1.10 RVU • 99215 (High Complexity) 2.67/1.77 RVU • 99381/91 (Prev Med 0-1 yo) 1.19/1.02 RVU • 99382/92 (PM 1-11 yo) 1.36/1.19 RVU • 99385/95 (PM 18-39 yo) 1.53/1.36 RVU • 99386/96 (PM 40-64) 1.88/1.53 RVU

10. What About Procedures? • Correct documentation of procedures are ESSENTIAL! • Procedure RVU’s are added to the E&M code • Ex: Visit for impaired hearing (E&M 99213 RVU = 0.67) + ear wax removal (RVU = 0.61). TOTAL = 1.28 RVU • IMPORTANT: Providers can receive credit for procedures done by ancillary staff.

11. What About Procedures? A Properly Coded Well Woman Exam can yield big RVU’s: • E&M Prev Med visit (99395) = 1.36 RVU • Procedure: Screening Pap Smear (HCPCS Q0091) = 0.37 RUV, • 1.73 RVU for a 30 minute appt.

12. Sample Procedure RVUs • Circumcision 1.81 RVU • Ear Wax Removal 0.61 RVU • Excision of Skin Tags 0.77 RVU • I&D Abscess 1.17 RVU • Punch Biopsy 0.81 RVU • IV Fluid, 1 hour 0.17 RVU • Nebulizer Treatment 0.32 RVU • EKG Reading 0.17 RVU • Cryotherapy of skin 0.76 RVU • Screening Pap by Physician 0.37 RVU • IM/SC Injection 0.17 RVU • Oxygen Sat Reading 0.04 RVU

13. Preventive Medicine Visits • There are different E&M codes for preventive medicine visits (well woman, well child). • These visits usually result in more RVU’s and assume a comprehensive history and physical. These are age based which CHCS II does automatically calculate • Again, you have to manually select this, by selecting PREV MED EVAL/MGT from drop down menu. A 99214 (Outpt visit, existing patient) = 1.1 RVU A 99395 (Prev Med visit, existing patient) = 1.36 RVU A 26% RVU increase!!!

14. The “Usability AIM” I highly recommended to NOT add this to your Default Encounter Template. Will take too long to load Step by step instructions on adding it to your My Favorites List is described at the end of this presentation. As long as you just add (not save) it to your favorites, it will auto-update automatically when changes are needed. As opposed to copying it and saving it as your personal AIM template. Please check periodically for updated versions by searching “Usability” periodically, and adding in the most recenty dated Usability AIM Form (as described at the back of this presentation)

15. Use the HPI/Screening Tab for Chief Complaint and past history, family history, and social history

16. Can type Chief Complaint here. You may indicate you reviewed allergies by clicking here

17. Rules for HPI. Up to 3 elements for a Brief, and an Extended HPI (99214 level) consists of at least 4 of 8 elements from the list. Tip: Remember DSMA: D = Duration S = Severity M = Modifying Factors A = Associated Sx’s DSMA Makes sense on every patient with a chronic disease. And easily done on all visits. Ex1. Extended HPI: Diabetes for 6 years. He is on oral medications. He is taking his medications, exercising and watching his diet. He has no numbness or tingling in his feet or legs. Ex2. Extended HPI: Patient complains of dull ache in right ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and Tylenol. Note: 95/97 coding guidelines say your staff can enter this for you.

18. If you click this button, you will see the additional coding step required in the disposition section if you use free text to document your HPI.

19. Clicking that button shows you that if you use free text in your note, and you covered 4 of 8 elements, you need to select the 2 button under HPI in the disposition section and Choose the “With user overrides” button to get the proper code. Note: Only needed if you believe the E&M Code should be a 99214 or above. This step not needed for a 99213.

20. A nice reminder here that to get a new line while typing in any free text box on an AIM Form, Use: CTRL + Enter. Use this box to free text your entire HPI.

21. You can click these boxes to indicate you reviewed the patient’s past history, or you can click them to free text these items. Only one of these boxes must be clicked for a 99214 level exam on established patients. On a New Patient, must check all three (PMH, Soc Hx and Family Hx). Should be a clinically pertinent review item to count.

22. As you use the bar to scroll down this tab you can get to other areas to enter historical information and JCAHO information. You or your screeners (hint) can address these items for you.

23. Other information on history can be entered here.

24. Addressing Tobacco and/or Alcohol here gives 1 credit point to Social History… WARNING: on these boxes. Only single click to enter numbers. Do not double click here. It will lock. If it locks, press the “tab” key 14 times, then press enter. If you lose count, alternate between “tab” and “enter” until the mouse frees up. Working to fix this in an updated version. Specific social and Female history

25. Scroll up to the top of this page and click the ROS tab.

26. Coding rules are listed at the top. 1 for Problem Pertinent. 2 -9 ROS must be covered for a 99214 (Extended level ROS) from 2 or more different organ systems, etc. Must be clinically important to get credit!

27. You can free text ROS in this box if you want to self code. To get credit for the constitutional system under ROS you can click N and free text, or you can click N to any of the other specific terms under the constitutional ROS.

28. HPI / ROS Flip for Readability If you wanted to use this form to document Abnormal HPI findings (i.e. need to click Y), and free text any further data. Then click the ROS button to flip this to an HPI item. This puts the abnormal finding and free text in the HPI section for better readability of the note. Note: AHLTA 3.3 will optionally flip this automatically

29. May scroll down to document more ROS. All main systems are covered.

30. Additional ROS. Note: the musculoskeletal tabs on this AIM form has more comprehensive musculoskeletal ROS.

31. Click the ‘PE’ tab to go to the physical exam Additional ROS

32. The top of the physical exam tab has coding reminders (Remember 1, 6, 12 and 18 corresponds to a 99212, 3, 4, and 5) Ex. The detailed level (99214 level) requires 12 bullets from 2 or more body areas. Must be clinically relevant to count!

33. Use the quick entry ‘Normal’ buttons to annotate that all findings listed to the right are normal.

34. Clicking Reviewed here will check all of the following vital signs as reviewed. The same applies to all other buttons labeled ‘Normal’. Clicking these square boxes opens up free text for free text entry.

35. The number next to the Body system listed shows you how many physical exam bullets you get for clicking each ‘Normal’ button

36. If you didn’t examine one of the findings listed, or one of the findings was not normal, you can click on the ‘X’ next to the finding to remove it.

37. Click ‘OK’ and the finding will be removed. Note: this extra step is removed from AHTLA 3.3

38. Thyroid is no longer checked.

39. Scroll down to document abnormal findings or just more findings.

40. A more comprehensive physical exam is possible in this section. The number next to the body area tells you the maximum number of physical exam bullets you can get in each section. To get a physical exam bullet, check one or more findings under a bolded term. Note: Checking NL Conjunctiva, NL Sclera, and NL Eyelids gives you 1 for the eye. But, NL Sclera and NL Optic Disc gives you 2, etc.

41. Scroll down for more physical exam options. Anything that doesn’t give you coding credit will be annotated. Here sinus tenderness does not give coding credit.

42. A more thorough heart and lung exam is possible here (with several PE bullets).

43. A very basic musculoskeletal exam is possible here, but we recommend you use the musculoskeletal specific tabs (tabs at top).

44. Gender specific findings will be “grayed out” and not selectable based on patient gender. Ex. Male specific findings will be “grayed out” and not selectable for a female patient.

45. Findings that were already selected with the quick entry tab will not be selectable in the complete PE (see lymph nodes above). Also note Cerebellar exam is a non-count.

46. Don’t forget to scroll up once you have completed your physical exam if you want to use other tabs, otherwise you may see blank on the next tab (just scroll up).

47. The musculoskeletal (upper) tab has several options for documenting both ROS and physical exam findings.

48. If you want to document a back exam, click the double arrow next to Neck/Back/Spine/Pelvis.

49. The tab will open up into a review of systems and a physical exam. The ROS here helps you document your “Red Flag” items from your low back pain evaluation.

50. One can document c-spine, t-spine, thoracolumbar spine, pelvis and a full back exam.