NextGen Procedure Template Problems: Fifty Shades of Evil

1. NextGen Procedure Template Problems:Fifty Shades of Evil The procedures templates have been rife with flaws since we started on KBM 7.8. Gradually over time some have been fixed, but many persist. Here I’ll list several problems I’ve discovered, & suggest some workarounds (if I can think of one). I need your help! There is no way I’ll ever be able to think of all the variations to test on the procedure templates. If you discover a problem that I have not documented here, please let me know. RL Duffy

2. ENMT Procedure Popups(That would be EENT to most of us) • As of this writing there are many flaws in the ENMT group of procedure popups. • I’ll describe one problem with the Ear popup in the following slides, but there may well be other problems I haven’t observed yet. • They are also not geared to be primary care-friendly. • I recommend NOT USING these templates at all.

3. Instead of the ENMT popups, look at Foreign Body Removal. This allows you to document cerumen removal, as well as ear, eye, nose, & skin foreign body removal (though it also has a small flaw I’ll mention later).

4. But if you really want to see this… Say you need to document & charge for cerumen removal. You would logically start by clicking Ear.

5. We’ll say that you’ve already added the diagnosis of Cerumen Impaction 380.4—though as we’ll see in a moment, that doesn’t do you any good.

6. But what do you do next? You don’t see anything about cerumen impaction. Nonetheless, you soldier on, & discover by sheer trial & error that you need to click Ear microscopy to proceed. If you’re not using a microscope you’re starting to feel a little uncomfortable, afraid you’re about to overcharge for a simple ear irrigation. But you have no choice but to go forward.

7. The next thing you see is this popup, with only 2 choices, neither of which is Cerumen Impaction 380.4. And why am I being asked this anyway? I’ve already selected a diagnosis—that’s the way it works on some other procedure popups, like Joint Aspiration/Injection. All you can do is cancel out of this popup—though, as we’ll see in a moment, that seals your doom.

8. Next you get this popup. So we go from 2 diagnoses to the entire ICD 9 library. Well, you’ve seen this nonsense before, so you click in the list & try typing Cerumen.

9. No luck, since you’re at the mercy of how the diagnosis is worded. E.G., is the magic word “Pharyngitis” or “Acute pharyngitis”? Anyway, you’ve played this game before as well, so you click Refresh to try again.

10. You could waste 10 minutes at this point playing “What am I thinking?” with this infernal tool (& I use the term very generously), but in this case you type Impact & it shows the correct diagnosis. You select Impacted Cerumen & click OK.

11. Next you get the Side popup. But first, if you’re watching carefully, you’ll notice the selected diagnosis bullet has moved to the 2nd, blank position. Whiskey Tango Foxtrot? But you go ahead & pick bilateral.

12. Type some comments, then click Submit to Superbill…

13. …and you’re rewarded with this error message, probably because the Ear DX 1 box is blank. The user has wasted a great deal of time, only to arrive at a dead end.

14. The entire Ear – Procedure popup suite needs to be reviewed with a fine tooth comb to purge it of errors like these. And if you’re going to display the diagnosis selection at the top, your selection there should count as the billing diagnosis for the procedure.

15. Lesion/Wart/Punch/Other Popup • In the past there have been numerous flaws & gotchas on this template. Many of these have been fixed over time, but as you’ll see, it still has issues. • It is a very involved template, with a lot of different things crammed in. As a result, one sequence of events may work correctly, while another leads to an error message. • Please report any additional misbehaviors you find to the EHR Team or myself.

16. There are a lot of disparate procedures here, & this presents some problems & lays some traps for the user.

17. First, if you do several different procedures, make sure to document ALL of them before clicking Submit to Superbill. It is intuitive to want to document one procedure, click Submit to Superbill, document the next procedure, click Submit once more, etc, but it won’t let you do that.

18. Also, since there are multiple procedures here you’re forced to document all at once, if you make a mistake or there is a program error message, it can be difficult to figure out just where on this template the problem lies.

19. You’ll notice the Locationpopups lack some entries you might want to have, e.g., forearm or chest. Fortunately, most all of these lists include a blank space at the top, which is your (usual, not 100% guaranteed) clue that you can free-type an entry. And note that in some boxes it will be appropriate to have more than one entry.

20. Notice there is no way to specify the other side for lesions after the first one. I guess patients must have all of their left-sided lesions done at one visit, & schedule another visit for the right-sided ones. Plan accordingly.

21. Note that after making an entry (often the location) the Number Pad popup immediately appears. It may not be readily apparent whether you’re talking about the size of something, or the number of something. To complicate matters further, the Number Pad popup may also overlie the fields in question, so you may need to slide it down a bit, as I’ve done here.

22. Here’s something that will help you distinguish the size from the number of lesions. When it is size the title of the popup is Number Pad, as shown on the previous slide. When you’re talking about number of lesions, the title is Quantity, as shown here. So why wouldn’t you title it Size for the size popup? Sheesh.

23. Note this 2nd Assessment box under Punch Biopsy. Unlike the other procedure sections, the 2nd Assessment popup is never spontaneously displayed during the workflow, so it remains unpopulated unless the user clicks directly into it. And shouldn’t the 2nd Assessment box be here, on the Each additional lesion line, like it is on all the other sections?

24. Why require the user to pick an assessment under Skin tag? The section itself defines the diagnosis code as 701.9. (Admittedly, it may be advisable to preserve this since there will be two different codes to pick from in ICD 10.)

25. You have a section to enter anesthetic & suture selections, but this presents several problems: • How would you indicate that you used 2% lidocaine on the hand shave biopsy, but 1% lidocaine with epi on the facial punch biopsy? • How would I enter 2 different types of suture? • Speaking of suture, there’s no 3-0? And how would I indicate deep absorbable sutures in addition to the skin sutures (though hopefully nothing here would require that)?

26. How do you deal with all of these issues? Your best bet is to use the Comments box. Use the checkboxes & picklists to do whatever you have to do to make the program happy & allow billing to be submitted. Then accurately describe the procedure(s) in the Comments box. Sometimes these boxes are problematic because they don’t give you enough space, but you’re allowed to type just under 1000 characters on this one.

27. If you do make a mistake & click Submit to Superbill before documenting all your procedures (& this popup & the “I just remembered, Doc” nature of patient presentations virtually guarantee this will happen to all of us), you can use the Superbill or the Generic procedure template to add the additional procedures, though it will require a knowledge of the diagnosis & CPT codes you wish to submit.

28. How could this popup be made better? It is a daunting task for the programmer. I suggest: 1) Divide this into several popups, with just ONE procedure type on each. I see the reasoning in trying to squeeze everything in here, but this would clarify usage, simplify troubleshooting, & allow us to submit each procedure type to superbill one at a time. While you’re at it, give us better options to document lesions on more than one side, different types of anesthesia, suture, etc.

29. 2) If you still want to keep everything on the same popup, adopt a Clear for Add model, like you use for many other popups. Every time we click the Clear for Add button, we’re given a clean slate & can submit to superbill again. But that could obviously present problems if the user submitted the same type of procedure as two “first lesion” charges instead of “first lesion, second lesion.” That’s why option #1 is better. 3) Another alternative would be to have a separate Submit to Superbill button under each section. These would need to all be independent of each other—which could present a programming challenge.

30. 4) The CMS rules on how to submit charges for various types & numbers of skin surgery procedures are very convoluted & confusing. (It is tempting to conclude this is intentional.) It would be very helpful if you could label each section in plain language (or use [i] informational popups to do so), so that even the infrequent user could tell the difference between, e.g., placing one charge for lesions 1-14, & placing 14 charges for lesions 1-14. My preference would be to spell it out directly on the procedure popup rather than use informational popups, if you can do so without making it too cluttered.

31. Lesion Excision/Shaving Popup • There is a flaw here you need to be aware of, but the popup is still usable.

32. When you click Submit to Superbill, you get this error message. It doesn’t matter what combination of procedures you document, or how many. After clicking OK, however, you’ll get text saying “Charges submitted,” & a check of the superbill will confirm the charges are there. So just expect to have to click through this.

33. And why are we limited to only 4 procedures? Financial or time considerations may discourage you from doing very many of these at a time, but shave biopsies in particular are very quick, & doing more than 4 at a time is not unprecedented in our practice.

34. “Could not add a new patient procedure” isn’t done with you yet • This flaw exists on other procedure popups as well. Those I’ve discovered so far: • Foreign Body Removal • Incision & Drainage • Lesion Excision/Shaving • Nail Avulsion/Hematoma/Removal (with additional issues)

35. As above, a check of the superbill will confirm the charges are there. So always expect to have to click through this, then confirm the charges actually show on the superbill.

36. Nail Avulsion/Hematoma/Removal Popup • There is a flaw here you need to be aware of. • With some persistence, however, the popup is still usable.

37. Here I’ve documented a nail procedure, so let’s click Submit to Superbill.

38. The Nails – Procedure popup closes, you’re dropped back to the Procedure Template, & you get this error message. When you check the superbill, you’ll see that, indeed, the charges are not there. Note: This doesn’t happen every time; there may be some magic sequence of events that brings it on.

39. Out of sheer stubbornness, since you’ve been working on this abomination for over 5 hours now, you open the Nails – Procedure popup again, & once more click Submit to Superbill…

40. You see a popup telling you it couldn’t add a new procedure, but red text telling you this time “Charges submitted.” When you click OK, then Save & Close, this time you’ll check the superbill & find that the charges are submitted this time.

41. The only thing worse than behaving badly is behaving inconsistently& badly. Using the procedure templates is a demonstration of the principle of intermittent reinforcement. Gamblers Anonymous needs to warn its members not to use this program.

42. Laceration Repair Popup • This is usable, but there are limitations

43. Seriously, have you never heard of 3-0 nylon? In the land of hurricanes & poor chainsaw skills we use a lot of this. Not to mention chromic deep sutures.

44. More importantly, have you never heard of “Knife And Gun Club?” There is no way to document more than one simple or intermediate laceration repair on any body region. In particular, multiple simple lacerations to Scalp/extremities/trunk are very common. Providers, the only way I see to document multiple laceration repairs of the same type/body area is to figure out the diagnosis & CPT codes, & use the Generic Procedure template to enter them, or enter the charges directly on the superbill, making sure your visit note documents the details of the repair.

45. Generic Procedure Popup • OK, we’ve talked about using the Generic Procedure popup several times, but riddle me this: What are you supposed to do if you need to use it more than once?

46. So I’ve documented one simple torso laceration repair on the Laceration Repair popup, & I’ve documented her Nexplanon placement. How do I document repairing the 2nd & 3rd simple torso laceration repairs? OK, maybe you don’t think I’m doing laceration repairs & Nexplanon placements on the same patient, but the problem would arise with anyone with 3 same-region simple lacerations to repair. Shouldn’t the Generic Procedure popup reset every time we launch it, so that we can submit another procedure? And while we’re at it, it would be helpful if we had a procedure popup for intradermal contraceptive placement & removal so we wouldn’t have to use the Generic popup.

47. Nebulizer Treatment • I’ll close with this head-scratcher.

48. Why isn’t Nebulizer Treatment under the Pulmonary heading? Just what the heck else are you nebulizing? Never mind—do NOT tell me.

49. In Conclusion • Since I mentioned 50 in the title, I should probably stop before hitting 50 slides. • Unless you’ve lived through earlier versions, you won’t believe me when I tell you this is still WAY better than it used to be. • Hopefully this will help you recognize & work around some of the stupid pet tricks which lie in wait on the procedure templates.

50. This concludes the NextGen Procedure Template conniption. Out of my mind. Back in five minutes. R. Lamar Duffy, M.D. Associate Professor University of South Alabama College of Medicine Department of Family Medicine