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Admission/Discharge/Transfer (ADT), Coding & Error Resolution

Admission/Discharge/Transfer (ADT), Coding & Error Resolution. RPMS EHR Inpatient. Admission/Discharge/Transfer (ADT). Pre-implementation Check-List PIMS ADT User’s Manual Jan 2009 ww.ihs.gov PCC Supervisor’s Manual www.ihs.gov IHS Chapter 3, HIM Manual www.ihs.gov

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Admission/Discharge/Transfer (ADT), Coding & Error Resolution

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  1. Admission/Discharge/Transfer (ADT), Coding & Error Resolution RPMS EHR Inpatient

  2. Admission/Discharge/Transfer (ADT) • Pre-implementation Check-List • PIMS ADT User’s Manual Jan 2009 ww.ihs.gov • PCC Supervisor’s Manual www.ihs.gov • IHS Chapter 3, HIM Manual www.ihs.gov • Present on Admission Site Parameters (PCC)

  3. Things to Consider… • Admit/Discharge orders (Date/Time) • Setup ADT Files (System Definition Menu) • Treating Specialty (OB, NB, GM, PEDS, OBS) • Room-Bed • Ward • Switch Bed (SWB) • Ward Transfer (WTX) • Attending physician (Change Provider when there is an order) PCH Provider Change

  4. Things to Consider cont’d… • Against Medical Advice (AMA), Absent without Leave (AWOL), Patient on PASS • Discharge from Observation to Admit to acute care (time must be 1 minute after discharge from observation) • Intra-facility transfers (ward, treating specialty) • There must be an order from the attending physician to transfer from one ward to another, and from one provider to another provider (SWP)

  5. Things to Consider cont’d… • Discharge • Time of Discharge (discharge orders and nursing discharge) • Correct discharge treating specialty (Mnemonic: IP) • Transfer to an IHS or non-IHS facility (build your own list) • Admission/Discharge Type/Source • IHS • UB-92 It is important to admit, discharge, and transfer in a timely manner!

  6. Discharge Summary • PCC Inpatient Supplemental & Discharge F/U Record, IHS-485 (not required) • D/C Summary Tab v. Dictated DS • Discharge Summary template • Present on Admission (POA) Parameters • Acute Care v. Critical Access Hospital • POA (may be added to the template) • Importing data objects into the template (med list, labs, patient education codes)

  7. POA Parameters UPDATE PCC DATA ENTRY PARAMETERS SITE NAME: DEMO HOSPITAL • ************************************************************************ • UPDATE DEFAULT PARAMETERS (press enter): FORMS TRACKING? (Y/N) Y • UPDATE DISPLAY PARAMETERS (press enter): ASK OUTSIDE LOCATION? (Y/N) Y • Prompt for VISIT CREATION? (Y/N) Y ASK PROVIDER EVENT TIME? (Y/N) • PROMPT FOR MODIFIERS WITH CPT ENTRY? YES PROMPT FOR MODIFIER ON POV? N • ASK WALK-IN/APPT FOR CLINIC? (Y/N) Y • TYPE OF PROCEDURE CODING: ICD OPERATION CODING • Require Present on Admission (POA) for Hospital Stays? ? • Choose from: • 1 DO NOT REQUIRE POA - CRITICAL ACCESS HOSPITAL • 0 REQUIRE POA

  8. Present on Admission Enter PURPOSE of VISIT: HTN 401.9 (HYPERTENSION NOS) UNSPECIFIED ESSENTIAL HYPERTENSION OK? Y// PRESENT ON ADMISSION?: Choose from: Y YES N NO U UNKNOWN W CLINICALLY UNDETERMINED 1 UNREPORTED/NOT USED (Exempt Codes) PRESENT ON ADMISSION?: Y YES

  9. Inpatient A Sheet • 25 Admitting Diagnosis Insurance Coverage • DIABETES II/UNSPEC NOT UNCONTR (250.00 • -------------------------------------------------------------------------------- • 26 ICD9 27 POA 28 Established DX • 250.00 X DIABETES MELLITUS CONTROLLED • 401.9 HYPERTENSION • 496. CHR OBSTRUCTIVE PULMONARY DISEASE

  10. Coding • Use of Historical diagnoses (pertinent to the inpatient stay) • Adding a Diagnosis • E&M codes • Initial • Subsequent Days (Daily) • Discharge Management • Observation • Present on Admission Documentation (Coders enter codes/POA Indicators in ADT) • Final A Sheet vs. A Sheet worksheet • Inpatient Deficiencies

  11. In-Hospital Visits • Description • A patient seen by a consultant while in the hospital, e.g., receiving physical therapy treatment during a Hospitalization. • Link In-Hospital Visits to Hospitalizations (INP) • AUT Link In-Hospital Visits to Hospitalizations • MAN Manually Link In-Hospital to H Visit

  12. TIU and ADT Reports • TIU SSD option should be used to monitor and track incomplete documents • Unsigned, Signed, by provider, Date range, Progress Notes, Discharge Summaries • ADT Reports Menu (RM) • Current Inpatient Listings • Provider's Incomplete Charts • Incomplete Chart Reports (ICR) • Listing of Coded A Sheets • Operators' Inpatient List • Incomplete Chart Statistics (ICS) • Inpatient Coding Status Report • Incomplete/Delinquent Statistics by Provider

  13. Daily/Monthly Census • Admissions & Discharges Sheet (ADS) • Monthly Census (M202) (CEN) • Yearly Census (Y202) (CEN)

  14. Correcting Errors • Changing Note Title • Retracting a Note (Justification documentation) • Reassign Note

  15. Questions?

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