The Interaction between Documentation and Coding within AHLTA

1. The Interaction between Documentation and Coding within AHLTA MAJ Jacob Aaronson, DO Army OTSG, Office of the CIO UBU Conference 15 March 2006

2. Overview • Clinical Perspective • Business Perspective • Relationship between structured data and accurate E&M • AHLTA coding capabilities • Existing • Future enhancements • Demonstration jacob.aaronson@us.army.mil V2.1

3. Clinical Perspective • EMR should facilitate clinical workflow • Byproduct of comprehensive documentation should be accurate coding • EMR should provide coding “decision support” • Clinician focus is patient care, not coding • Effective feedback loop with coding community is a necessity • Automation cannot improve process jacob.aaronson@us.army.mil V2.1

4. Understanding and Improving Coding in AHLTA“The short course” jacob.aaronson@us.army.mil V2.1

5. SOAP MEDCIN HPI Tab Subjective PFSH Tab ROS Tab Objective Physical Exam (PE Tab) Assessment A/P Module Plan jacob.aaronson@us.army.mil V2.1

6. E/M Calculation SOAP MEDCIN HPI Elements HPI Tab Subjective PFSH Tab PFSH Elements ROS Tab ROS (Number of Systems) + Objective Physical Exam (PE Tab) PE Tab (Specific Elements And Effected by Type of Exam, Patient Status) Assessment A/P Module + Plan Diagnosis (Medical Decision Making – Algorithm Based) jacob.aaronson@us.army.mil V2.1

7. Background • Many user do not understand the previous relationships • Issue – Many users complain about the “speed” of documentation with AHLTA and its ability for multiple people to enter information into the note. • Speed – The time it takes to complete the entire healthcare encounter from check in to a completed note. • Training – Usually focuses on capabilities of the system NOT how to use AHLTA to improve healthcare delivery and your workday. • Documentation – A team responsibility • Solution – The best way to improve speed and effectiveness is to understand how AHLTA assists in the process of care and how this relates to business of care. jacob.aaronson@us.army.mil V2.1

8. Scenario 1 • OUTCOME – Multiple entries during a single encounter where separate time/date stamps are needed. • Nurse/Tech writes initial note or enters serial notes. • Provider writes ADDITIONAL note(s) that are emitted separate from the Nurse/tech’s note. • All entries into the encounter stored in chronologic order. • Use Cases • Note started by Triage Nurse in Emergency Department • Documentation of Serial exams • Nursing documentation of intervention (IV fluids, nebulizer treatment, medication during the visit) • Transition of care between provider (i.e. Change of shift) jacob.aaronson@us.army.mil V2.1

9. Scenario 1: Here is the technician’s note. Subjective information is collected for the provider or it could be someone doing triage. jacob.aaronson@us.army.mil V2.1

10. The provider or second person clicks the S/O Button, and this is the window presented. If the provider wants to just add an additional entry to the note, then the provider should click, ‘New Note’. jacob.aaronson@us.army.mil V2.1

11. Note the technician’s note is intact above the doctors note. The provider’s or second person’s entry has a new signature and time/date stamp. jacob.aaronson@us.army.mil V2.1

12. Scenario 2 • OUTCOME • Provider wants to leverage the data/information that the Tech/Nurse has gathered. • Provider takes over the tech/nurses note (edit) and the tech/nursing note shows up at the bottom of the page (for auditing purposes). • Tech/Nurse documents initial data and an initial note is generated. • Provider assumes responsible for the encounter and completes the encounter with a single time data stamp. This makes a more legible note for the next person to read – as well as allows the sharing of data entered. • Use Case: Typical Office Visit (at least the start of one). jacob.aaronson@us.army.mil V2.1

13. Scenario 2: Here is the technician’s note. Subjective information is collected from the patient as agreed by the healthcare team. jacob.aaronson@us.army.mil V2.1

14. The provider clicks the S/O Button, and this is the window presented. Provider click’s edit note. jacob.aaronson@us.army.mil V2.1

15. Note: Try hard to avoid reading this pop-up (as it is very confusing), • Just click ‘No’. • You will get another pop-up. jacob.aaronson@us.army.mil V2.1

16. Provider: Now click ‘Yes’ jacob.aaronson@us.army.mil V2.1

17. Provider completes S/O portion of note with their default encounter template or AIM form. The result of this is just one S/0 note - the provider’s note - and the information entered by the nurse/technician’s is moved to the change history. jacob.aaronson@us.army.mil V2.1

18. Business Perspective • Documentation should clearly and accurately support E&M, ICD, CPT coding • With an EMR capable of coding, the role of a coder shifts to auditor • Effective feedback loop with clinical community - focused on areas with ROI - is a necessity jacob.aaronson@us.army.mil V2.1

19. The Macro View of AHLTA:Structured Term Use per E&ME&M Code DistributionProductivity Impact 3.3 Million Encounters 8/21/2005-11/26/2005 Data Source: CDR Note: Data is raw data from provider visit without coder review or intervention. jacob.aaronson@us.army.mil V2.1

20. # MEDCIN Terms in S/O vs. E/M Code jacob.aaronson@us.army.mil V2.1

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24. Comparison of AHLTA FP Est. Outpatient Visit E&M Code Distribution to Medicare and Recommended Distribution jacob.aaronson@us.army.mil V2.1

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26. MTF Productivity and AccessAMEDD AHLTA Use Impact FY 04 and FY 05 Data Source: PASBA jacob.aaronson@us.army.mil V2.1

27. Encounters/FTE from FY04-05(From B MEPRS Clinics) 05 Avg 04 Avg 12 mo 10 mo 12 mo 12 mo 10 mo 12 mo 10 mo 12 mo 12 mo 12 mo 12 mo 12 mo 7 mo 9 mo 2 mo 9 mo 1 mo 3 mo Sill Lee Polk Bliss FY04 Eustis Gordon Rucker Stewart Jackson Benning Redstone Campbell Wainwright FY05 * Numbers in each column indicate the months using AHLTA during that FY jacob.aaronson@us.army.mil V2.1

28. RVUs/FTE from FY04-05(From B MEPRS Clinics) 05 Avg 04 Avg 12 mo 10 mo 12 mo 12 mo 10 mo 12 mo 10 mo 7 mo 9 mo 2 mo 9 mo 1 mo 3 mo Sill Lee Polk FY04 Bliss Eustis Gordon Rucker Stewart Jackson Benning Campbell Redstone Wainwright FY05 * Numbers in each column indicate the months using AHLTA during that FY jacob.aaronson@us.army.mil V2.1

29. Conclusion • There is a general expected correlation between the number of MEDCIN terms used and the resulting E/M code through level 4 E&M codes • The E/M distribution pattern from AHLTA use is as expected and consistent across services • AHLTA implementation has occurred simultaneously with an increase in provider productivity. jacob.aaronson@us.army.mil V2.1

30. Recommendation • Focused analysis on MEDCIN term use to improve education on note writing (Status: In progress) • Continue trending MTF productivity but publicize present finding to change myths. • Evaluate need to change the present E/M “accuracy” metric and instead focus on E/M distribution level • Evaluate coder utilization and cost in AMEDD against ROI with plan to focus coding expenses on areas with known ROI • Need to insure all data captured in AHLTA is sent and accepted by SADR jacob.aaronson@us.army.mil V2.1

31. Common Errors within AHLTA • E&M under-coding can occur with AHLTA. This is most commonly due to inappropriate use of free text or using a template that was not designed to accommodate optimal documentation resulting in a higher code. • Failure to use a Vcode for physicals and to select a Prev Med Eval/MGT Services Type for the visit in the Disposition Module. • Failure to select the proper EXAM TYPE for subspecialty areas in the Disposition Module. • Example: The coding rules change for ENT-specific exam vs. a general medical exam. • Failure to document common office procedures (CPTs) that were done (Pulse ox, EKG, immunization, etc) • Failure to use modifier codes with visits (such as a -25 modifier when a patient comes in for two distinct problems) jacob.aaronson@us.army.mil V2.1

32. AHLTA Coding CapabilitiesExisting • S/O capture of Medcin terms • Templates • AIM forms • A/P • Diagnoses • Procedures • Disposition module Encounter Templates jacob.aaronson@us.army.mil V2.1

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36. AHLTA Coding CapabilitiesEnhancements • Set E&M user defaults – (have a direct bearing on the calculated value for the E&M code) • Setting and Service Type • Control the overall category of E&M codes that will be used in the calculation • Exam type • Can adjust the level calculated for the Physical Exam • (only relevant to the “1997 Guidelines” for E&M calculation--the guidelines that are currently utilized in the E&M calculator in AHLTA) jacob.aaronson@us.army.mil V2.1

37. AHLTA Coding CapabilitiesEnhancements • Automated inclusion of certain encounter data in E&M and procedure coding: • Pulse Ox, Peak Flow, visual acuity - automatically populate the appropriate CPT in A/P module • All Vital Sign data included in the E&M Calculation • AutoCited Problem List and Family History information included in the E&M Calculation • All diagnoses to be included in the Medical Decision Making (MDM) component of the E&M Calculation • Orders information to be included in the MDM component of the E&M Calculation. jacob.aaronson@us.army.mil V2.1

38. AHLTA Coding CapabilitiesEnhancements • “V code use” and MDM changes: • Prompt the user for proper “V Code” use for Preventive Medicine Evaluation visits • Simplify the method by which a provider may override the MDM component of the E&M calculation.. (as appropriate) • Coding information resource links include the following: • Addition of Government-specified coding resource web site links into the favorites list in the Web Browser module of the application. jacob.aaronson@us.army.mil V2.1

39. AHLTA Coding CapabilitiesEnhancements • Integrated Immunizations • Capability to provide coding support and documentation for workload credit when immunizations are documented in the Immunization module. • Capability to save procedures associated to immunizations to the A&P Module. jacob.aaronson@us.army.mil V2.1

40. AHLTA and Coding • Continue to analyze MEDCIN term use to improve education on note writing • Focus on E/M Distribution Reports instead of E/M “accuracy” metric • Automate E&M coding user defaults and enhancements • Understand and use modifiers • Document procedures • Improve processes • “Immunization” clinics • Linkage of work (RVU) to encounter and provider • Healthcare team documentation • Refine coder support jacob.aaronson@us.army.mil V2.1

41. Demonstration

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