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Pharmacy Paperless Refill. Presenters : Angela Kihega, RHIT Oklahoma City Area HIM Consultant Amy Rubin, PharmD Oklahoma City Area Clinical Applications Coordinator. Learning Objectives. Review the process for Paperless Refill from the Pharmacist’s perspective.
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Presenters:Angela Kihega, RHITOklahoma City Area HIM ConsultantAmy Rubin, PharmDOklahoma City Area Clinical Applications Coordinator
Learning Objectives • Review the process for Paperless Refill from the Pharmacist’s perspective. • Compare and contrast .9999 and 999.9 ICD-9 Codes as they apply to Paperless Refill. • Fix UNCODED ICD9 Diagnoses/Operations for Paperless Refill • Review and Complete Paperless Refills using the EHR Coding Queue by Clinic Code • Understand the significance of Pharmacy 12:00 and 13:00 visits • Understand the use and sequencing of the V-Code and Diagnosis Code
Paperless Refill • Electronic documentation of pharmacy only or outpatient clinic-initiated refill visits • Automatically prompts the pharmacist to select POV for each medication refill processed • Automatically populates necessary EHR fields to complete a pharmacy visit • Not necessarily paperless
Paperless Refill (Scenario 1) POV with Diagnosis “No errors” • Select PAPERLESS REFILL Option • Select POV from PROBLEM LIST • Inserts DIAGNOSIS from the PROBLEM LIST as the SECONDARY POV • V68.1 is the PRIMARY DIAGNOSIS
Paperless Refill (Scenario 2) POV with an Uncoded Diagnosis of .9999 Code • Pharmacist Bypasses selecting a Problem List DIAGNOSIS • Then Pharmacist enters ^ (Shift 6) to FREE TEXT a diagnosis instead • Using a FREE TEXT diagnosis results in a .9999 Error Code as a Secondary Diagnosis • Primary Diagnosis is V68.1
Paperless Refill (Scenario 3) POV with a 999.9 (Complicated Med Care NEC/NOS) • Pharmacist bypasses selecting a diagnosis by using the Shift 6 (^) option • System automatically assigns a 999.9 (Complicated Med Care NEC/NOS) code as the SECONDARY diagnosis • Primary diagnosis is V68.1
Pharmacy Visits12:00 vs. 13:00 • New prescriptions generate a visit with a time stamp of 12:00 • Prescriptions processed using Paperless refill generate a visit with a time stamp of 13:00 • Pharmacy visits can generate multiple visit entries for the same encounter • Ex: Same Day Visits with 12:00 and 13:00 time Stamp
When to say NO to paperless refill New prescription +Refill request = NO at paperless refill promptThis results in only one pharmacy visit … only one! Optional: add POV for refills in EHR
PCC Uncoded POV Report Menu PCC Patient Care Data Entry Menu ... DEU Data Entry Utilities ... SUP Data Entry SUPERVISORY Options and Utilities … ICD Fix UNCODED ICD9 Diagnoses/Operations ... POV Fix Uncoded Purpose of Visit Diagnoses