Documenting and Coding Procedures in AHLTA

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Documenting and Coding Procedures in AHLTA

• 19 December 2006
• LCDR J. George

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Why is it important?

• Correct documentation of procedures is ESSENTIAL!
• Procedure RVUs are added to the EM code.
• For example visit for impaired hearing (EM
  99213 0.67) ear wax removal (RVU 0.61).
  TOTAL 1.28 RVU
• IMPORTANT Although the RVUs are counted and
  billed under the provider, the RVU total is a
  measure of the healthcare teams work.
• Procedures need to be documented completely in
  order to get full credit for completing the work

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Sample Procedure RVU

• Circumcision 1.81 RVU
• Ear Wax Removal 0.61 RVU
• Excision of Skin Tags 0.77 RVU
• ID Abscess 1.17 RVU
• Punch Biopsy 0.81 RVU
• IV Fluid, 1 hour 0.17 RVU

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Procedure RVU

• Nebulizer Treatment 0.32 RVU
• EKG Reading 0.17 RVU
• Cryotherapy of skin 0.76 RVU
• Screening Pap by Physician 0.37 RVU
• IM/SC Injection 0.17 RVU
• Oxygen Sat Reading 0.04 RVU

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What should be documented

• Generally the following items should be
  documented
• Procedure name
• Operator
• Assistant
• Informed consent/risks
• Prepping and draping
• Describe procedure
• Complications
• Pathology
• Disposition

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How to document in AHLTA

• Use AIM form
• Use Medcin template
• Users may modify this to suit their needs. The
  important point is that they document completely.

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AIM Forms

• Easy to use visually appealing
• Cant be easily modified
• General Family Medicine AIM also includes tabs
  for colposcopy/laryngoscopy and vasectomy
• Can be used in combination with Medcin tree

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This template has a tab for a minor procedure
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Template

• These are the Medcin templates
• Can be edited by user
• Layout may not be as appealing as Form
• User can also choose to combine with Form

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(No Transcript)
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Coding a procedure in AHLTA

• A/P Tab
• Select appropriate ICD-9
• Select appropriate CPT/HCPCS code
• Select unit of service
• Select modifier
• Select additional provider

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1) Select procedure tab
2) Highlight code
3) Click on Add to Encounter
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Click on Modifiers icon to get this dialog box
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Check to make sure EM code is correct. Should
be 99499 if the visit was for the procedure only.
Change Service Type to Other Unlisted EM
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Set up in AHLTA

• Provider should receive guidelines from coding on
  how to code their procedures (what CPT or HCPCS
  codes to use and when to use units of service and
  modifiers)
• Providers should set up encounter templates that
  include either the AIM form or template plus the
  appropriate CPT/HCPCS codes. Ask superusers,
  clinical champions, and template managers if in
  place at MTF to make the templates.

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Backup Slides

• The following slides include the top 10
  procedures for the clinics
• B ENT Clinic
• B Family Practice
• B Gen Surgery
• B Gynecology
• B Orthopedics
• B Pediatrics

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ENT
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Family Medicine
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General Surgery
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Obstetrics Gynecology
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Orthopedics
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Pediatrics