Overview

1. Title: Enhancing Clinical Documentation withthe Tri-Service Workflow (COMPASS) Speakers: Sandra Kunze and Charles Motsinger Session: R-5-0900

2. Overview How the Tri-Service Workflow assists with documentation requirements Why Coders are integral members of the Workflow team

3. Coding E&M coding is complex Providers need tools to quickly and accurately determine E&M coding AHLTA coding calculator is unreliable and inaccurate The Tri-Service Workflow coding method delivers simplified tools for accurate, rapid E&M coding But it’s not enough…

4. Tri-Service Workflow Focus • Established patients: focus on history & MDM • History • Workflow is built to have a clinically appropriate detailed history • Workflow delivers : “CC/ 4:2:1” = detailed • Chief complaint • 4 (5) bullets for HPI “duration, severity, pain rating, associated symptom and modifying factors” • 2 Review of Systems (ROS), 1 bullet from 2 systems • Occupational and neurological • All Elements from PMHx, PSHx, Family Hx, Medications

5. Documentation • Code conditions that impact the encounter • Hypertension • Diabetes Mellitus • Asthma • Congestive Heart Failure • Parkinson’s Disease • COPD • Emphysema

6. Tri-Service Workflow Simplified Coding NOTE: Clinical necessity determines your work. Do not work toward a code. A “Yes” response to any one of the items below gives a 99214 *(Est Pt)** • 3 Established Problems Stable or Improving (addressed in Subj) • 1 Established Problem + 1 Established Problem Worsening (both addressed in Subj) • 1 New Problem (not self limited or minor, new to the provider) + Rx (not OTC med) • Review and Summation of Old Note + Rx (not OTC med) • Order Rad/ECG + Independent Review + Rx (not OTC med) *Three assumptions: 1. Detailed History has been accomplished (CC:4:2:1) 2. This is an established patient 3. CODING IS BASED UPON DOCUMENTATION IN THE NOTE (e.g., new problem must be stated as such in note, etc.) **If the answer is “no” to all questions above, the code is a 99213 UNLESS the patient has 1. Only one problem which is self-limited/established stable AND 2. Minimal data review or minimal management (rest/Band-Aids, salt water gargles, etc.)- then it is a 99212

7. Accurate Coding • Document smarter • Support staff focuses on past medical history items, ROS and Joint Commission/HSI • Provider focuses on HPI (the story), PE, A/P

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11. When to Trust/Not Trust AHLTA • Override coding calculator • Will often have to override for Est and New patients • You can trust AHLTA for • Coding based on time • Greater than 50% of encounter with counseling & coordination of care – time-based coding • Time spent counseling and coordination of care • Total time spent • What was counseling about • Why the extra time was needed • Coding Preventive Health Visits

12. To Override AHLTA’s Coding Calculator From the Disposition screen, select the SELECTION tab Now highlight the code you want to assign to this encounter. Sample Procedures with RVU’s

13. Tri-Service Workflow Coding • Based upon and consistent with CMS 1997 coding guidelines • Compliant with MHS Coding Guidance

14. Is This Gaming the System? No, provided all information documented is medically relevant to the encounter Follow MHS Coding Guidance Based upon but not identical to Center for Medicaid and Medicare (CMS) and American Medical Association (AMA) guidelines

15. Tools to Improve Coding • BDQAS (AF Metrics) • 1995 and 1997 E&M Documentation Guidelines • AHLTA based on ’97 • DoD Coding Guidelines • Service Audits • AHLTA • Tri-Service Workflow AIM form and other workflow based AIM forms • Encounter Templates • Favorites List • Workflow

16. Coders/Auditors Are Vital Members of the Team

17. Why are Coders/Auditors are Integral to Workflow? • You are the coding SME • Extensive knowledge of all aspects of coding • Simplified coding only address the most common E&M scenarios • Providers need training on CPT and ICD-9 coding • Onsite and in the trenches • Coding instruction and feedback is most valuable to providers when it is combined with AHLTA training

18. Air Force Combined Audits and Training • Members of workflow Audit/Training Team • Coders/Auditors • AHLTA trainers • AFMSA/SG6 Workflow Division team members • Remote charts reviews accomplished with team • Feedback given to providers and SGH • Training can be targeted to specific coding deficiencies • Helpful AHLTAtools can be taught by AHLTA trainers in conjunction with the Auditor/Trainer to address the coding deficiencies • YOU ARE KEY MEMBERS OF THIS TEAM!

19. Workflow Research Results JC/HSI

20. Workflow Research Results RVUs RVU per encounter Provider Entered CorrectedPre Compass Staff0.9721.054Post Compass Staff1.2691.241Provider Entered CorrectedPre Compass Intern0.9431.067Post Compass Intern0.9711.045

21. Workflow Research Results Coding Accuracy

22. Summary • The Tri-Service Workflow Simplified Coding is a 25% solution • Coders/Auditors are vital members to the workflow and address the other 75% of coding areas

23. Questions

24. Speaker Information Session: R-5-0900 Sandra Kunze, CPC, CPC-H, CPMA, CHCO Coding Compliance Coordinator AFMOA/SGHC sandra.kunze.ctr@us.af.mil Lt Col (Dr) Charles Motsinger, LAc Chief of the Workflow Division SG6/ AFMSA charles.motsinger-02@afncr.af.mil