The Interaction between Documentation and Coding within AHLTA

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The Interaction between Documentation and Coding
within AHLTA

• MAJ Jacob Aaronson, DO
• Army OTSG, Office of the CIO
• UBU Conference
• 15 March 2006

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Overview

• Clinical Perspective
• Business Perspective
• Relationship between structured data and accurate
  EM
• AHLTA coding capabilities
• Existing
• Future enhancements
• Demonstration

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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

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Understanding and Improving Coding in AHLTAThe
short course
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SOAP
MEDCIN
HPI Tab
Subjective
PFSH Tab
ROS Tab
Objective
Physical Exam (PE Tab)
Assessment
A/P Module
Plan
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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)
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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.

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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/techs 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)

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Scenario 1 Here is the technicians note.
Subjective information is collected for the
provider or it could be someone doing triage.
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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.
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Note the technicians note is intact above the
doctors note. The providers or second persons
entry has a new signature and time/date stamp.
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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).

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Scenario 2 Here is the technicians note.
Subjective information is collected from the
patient as agreed by the healthcare team.
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The provider clicks the S/O Button, and this is
the window presented. Provider clicks edit
note.
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• Note Try hard to avoid reading this pop-up (as
  it is very confusing),
• Just click No.
• You will get another pop-up.

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Provider Now click Yes
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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
providers note - and the information entered by
the nurse/technicians is moved to the change
history.
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Business Perspective

• Documentation should clearly and accurately
  support EM, 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

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The Macro View of AHLTAStructured Term Use per
EMEM 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.

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MEDCIN Terms in S/O vs. E/M Code
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Comparison of AHLTA FP Est. Outpatient Visit EM
Code Distribution to Medicare and Recommended
Distribution
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MTF Productivity and AccessAMEDD AHLTA Use Impact

• FY 04 and FY 05
• Data Source PASBA

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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
1 mo
9 mo
2 mo
9 mo
3 mo
Sill
Lee
Polk
Bliss
FY04
Eustis
Gordon
Rucker
Stewart
Benning
Jackson
Redstone
Campbell
Wainwright
FY05
Numbers in each column indicate the months
using AHLTA during that FY
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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
1 mo
9 mo
2 mo
9 mo
3 mo
Sill
Lee
Polk
Bliss
FY04
Eustis
Gordon
Rucker
Stewart
Benning
Jackson
Campbell
Redstone
Wainwright
FY05
Numbers in each column indicate the months
using AHLTA during that FY
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Conclusion

• There is a general expected correlation between
  the number of MEDCIN terms used and the resulting
  E/M code through level 4 EM 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.

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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

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Common Errors within AHLTA

• EM 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)

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AHLTA Coding CapabilitiesExisting

• S/O capture of Medcin terms
• Templates
• AIM forms
• A/P
• Diagnoses
• Procedures
• Disposition module

Encounter Templates
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AHLTA Coding CapabilitiesEnhancements

• Set EM user defaults (have a direct bearing on
  the calculated value for the EM code)
• Setting and Service Type
• Control the overall category of EM 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 EM
  calculation--the guidelines that are currently
  utilized in the EM calculator in AHLTA)

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AHLTA Coding CapabilitiesEnhancements

• Automated inclusion of certain encounter data in
  EM 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 EM
  Calculation
• AutoCited Problem List and Family History
  information included in the EM Calculation
• All diagnoses to be included in the Medical
  Decision Making (MDM) component of the EM
  Calculation
• Orders information to be included in the MDM
  component of the EM Calculation.

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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 EM
  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.

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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 AP Module.

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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 EM 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

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Demonstration
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