HIM HOT TOPICS VeHU Session 101

1. 1 HIM HOT TOPICSVeHU Session 101 August 21, 2007

2. 2 FACULTY Linda Nugent, Director, VACO Beth Acker, HIM Specialist Jacki Bebb, HIM Specialist Lois Hall, HIM Specialist Pam Heller, HIM Specialist Mary Johnson, HIM Specialist Karla Porter, HIM Specialist LindaLinda

3. 3 Issues Brief The updated issues brief can be found on the VeHU website along with this class presentation Linda � has many updates that we will not cover in this sessionLinda � has many updates that we will not cover in this session

4. 4 Software UpdatesPTF Fields No Longer Needed Added 7 new treating specialty codes: Cardiac Intensive Care, Pediatrics, Cardiac Surgery, Transplantation, Anesthesiology, PM&R Transitional Rehab, Surgical Step-down Added 5 new GRECC treating specialty codes Renamed 6 treating specialty codes Inactivated 3 treating specialty codes Eliminated Suicide Indicator prompt Eliminated Substance Abuse prompt Eliminated Legionnaire�s Disease prompt Eliminated Kidney Source prompt Eliminated Dialysis Type prompt Renamed all references of DXLS to PRINCIPAL DIAGNOSIS Changed Cost Distribution Report (CDR) Term to Monthly Program Cost Report (MPCR) MP 6 converted to Handbook format and is in concurrence PTF Training Manual updated and posted to HIM web page LindaLinda

5. 5 Software Updates (cont)ASCD Class III Service Connected Automated Monitoring (SCAM)/Service Connection Objective Update Tool (SCOUT) converted to Class I with added functionality. Software will only send encounters with a diagnosis in the 1st position that exactly matches the VBA rating disability to PCE without review - test sites asked that only the 1st dx be allowed to pass as they were concerned that the mapping would not catch all the encounters that could be set to NSC and thus billed Partial matches and NSC encounters will be sent for review - sites can decide whether to review any of the NSC encounters, time permitting 1st release does not Include interface with QuadraMed - scheduled for 2008 Enhanced reports Changes in VistA (PCE) at this point only; CPRS in 2008 Alpha testing done 5/07 Beta testing began 5/07 Release scheduled for August 31, 2007 Linda Benefits � varies for sites � coders review less in Qmed; workload flow for billing supervisor; because of changes from SC to NSC, were able to bill x amount more; clinic service report can be an education tool for providers; does not have to be �one more worklist�; report functions. The mapping was more specific than in the earlier class III release. It does not disrupt the workflow process but focuses on those cases needing coding or further evaluation up front. It removes those positive match SC cases which decreases the number of cases requiring an initial (eyeball) review. �For those facilities who contract out outpatient coding, that it would provide a vendor worklist of insured cases needing coding. Linda Benefits � varies for sites � coders review less in Qmed; workload flow for billing supervisor; because of changes from SC to NSC, were able to bill x amount more; clinic service report can be an education tool for providers; does not have to be �one more worklist�; report functions. The mapping was more specific than in the earlier class III release. It does not disrupt the workflow process but focuses on those cases needing coding or further evaluation up front. It removes those positive match SC cases which decreases the number of cases requiring an initial (eyeball) review. �For those facilities who contract out outpatient coding, that it would provide a vendor worklist of insured cases needing coding.

6. 6 Closeout/Census Change As of October 1, 2007, all updates to the Austin Corporate Franchise Data Center (CFD) must be received no later than the 14th day after the date of the encounter or discharge The fiscal year close-out will be the 14th of the month following the end of the fiscal year LindaLinda

7. 7 Joint VHA/DoD HIM Conference October 11, 2007, Philadelphia Convention Center Agenda Topics � Privacy Update, DoD/VA Joint Ventures, CHDR, Standardization and Terminologies, Consolidated Patient Account Center VA/DoD Breakout Sessions FORE Donations � see Laura Herbert HIM Professional and Mentor of the Year Nominations � see Jennifer Jelinek Jacki Conference has been approved, agenda under development. Please give to FORE. Please submit nominations for HIM professional and Mentor of the year. Looking forward to once again collaborating with our colleagues in the Department of Defense. Jacki Conference has been approved, agenda under development. Please give to FORE. Please submit nominations for HIM professional and Mentor of the year. Looking forward to once again collaborating with our colleagues in the Department of Defense.

8. 8 Computer Assisted Coding Lingologix Demonstration Project Commercial Clinical Natural Language Processing Tool Codes Free Text Puget Sound Health Care System Pilot Site Nine Month Timeframe Jacki - A pilot demonstration project has been approved. This pilot will test computer assisted coding software at the Puget Sound Health Care System over a nine month time frame. Questions should be directed to Susan Helbig or Jacki Bebb Jacki - A pilot demonstration project has been approved. This pilot will test computer assisted coding software at the Puget Sound Health Care System over a nine month time frame. Questions should be directed to Susan Helbig or Jacki Bebb

9. 9 HIM Clinical Coding Program Handbook Establishes policy for an efficient and effective clinical coding program Provides guidance Coding staffing requirements Coder scope of work Productivity and accuracy requirements Data capture requirements Pam HIM Clinical Coding Program Handbook establishes VHA policy that an efficient and effective clinical coding program is established, maintained and supported within each VA Medical Center by a qualified health information professional. The handbook also provides guidance on managing the program to include coding staffing requirements, coder scope of work, productivity and accuracy requirements, and data capture requirements. Release date is unconfirmed at this writing. Pam HIM Clinical Coding Program Handbook establishes VHA policy that an efficient and effective clinical coding program is established, maintained and supported within each VA Medical Center by a qualified health information professional. The handbook also provides guidance on managing the program to include coding staffing requirements, coder scope of work, productivity and accuracy requirements, and data capture requirements. Release date is unconfirmed at this writing.

10. 10 Revenue Activities Review HIM member of team Review coding activities Report findings and recommendations Recurring coding concerns found during RAR visits: Inconsistent use of the surgery package Inconsistent use of VistA reports (action required, AERR, etc.) Inconsistency in using the QuadraMed coding/billing tool Inconsistency in tracking coding productivity, coding accuracy, coding back-logs Pam Utilize the management reports/tools available in QuadraMed and VistA. Code all of the OR surgical cases in the surgery package. # completed - 23 (I counted all of the reviews with VISN 12 counted as 1 and Albany/Buffalo counted as 1) Here�s the list: FY06 Visits Completed VISN 17: Dallas, Temple, San Antonio VISN 12: Consolidated MCCF VISN 22: San Diego, GLA, Long Beach, Loma Linda, Las Vegas VISN 21: Palo Alto FY07 Visits Completed VISN 1: Boston, Providence, Connecticut, Togus VISN 3: NY Harbor, East Orange, Northport VISN 4: Philadelphia VISN 8: Miami, Bay Pines, West Palm Beach VISN 2: Albany / Buffalo VISN 7: Birmingham Pam Utilize the management reports/tools available in QuadraMed and VistA. Code all of the OR surgical cases in the surgery package. # completed - 23 (I counted all of the reviews with VISN 12 counted as 1 and Albany/Buffalo counted as 1) Here�s the list: FY06 Visits Completed VISN 17: Dallas, Temple, San Antonio VISN 12: Consolidated MCCF VISN 22: San Diego, GLA, Long Beach, Loma Linda, Las Vegas VISN 21: Palo Alto FY07 Visits Completed VISN 1: Boston, Providence, Connecticut, Togus VISN 3: NY Harbor, East Orange, Northport VISN 4: Philadelphia VISN 8: Miami, Bay Pines, West Palm Beach VISN 2: Albany / Buffalo VISN 7: Birmingham

11. 11 HIM Satellite SeriesDocumentation & Coding for Compliance VA Learning Catalog: Program Schedule http://vaww.sites.lrn.va.gov/vacatalog Live Broadcasts - 3rd Thursday @month, 11 am � 12 noon ET AAPC pre-approved continuing education Repeat Taped Broadcasts Content Distribution Network Contact Barbara Millas to suggest topics PamPam

12. 12 Web-based Coding Traininghttp://www.educode.com/VAEES Available 24/7 to any VA employee, contractor or volunteer interested in improving medical terminology, coding, documentation & compliance skills Self-enroll or enrolled by administrator New! Mosby�s Anatomy and Physiology More than 15,600 learners enrolled! PamPam

13. 13 Electronic Reports from Austin At least two people at each site should get electronic access New report format increases flexibility for sorting, etc. Beth More detail on reports available from Austin and how to obtain access is noted in the practice brief. It is apparent, by data that is in the Austin database, that some sites do not have any organized program to be sure that inpatient and/or outpatient workload is transmitted to Austin, corrected if necessary, and accepted. The suggested reports (such as the PTF 419 Report) will give you the tools and information to do this validation. Question: Can you give an example�tell them what reports�I have a feeling many never have looked at them�web link? I added the 419 above and in the first sentence referred them to the practice brief where the web link is�would you like more? Beth More detail on reports available from Austin and how to obtain access is noted in the practice brief. It is apparent, by data that is in the Austin database, that some sites do not have any organized program to be sure that inpatient and/or outpatient workload is transmitted to Austin, corrected if necessary, and accepted. The suggested reports (such as the PTF 419 Report) will give you the tools and information to do this validation. Question: Can you give an example�tell them what reports�I have a feeling many never have looked at them�web link? I added the 419 above and in the first sentence referred them to the practice brief where the web link is�would you like more?

14. 14 Transcription BPA OIG Mandate to Standardize Contract Language Development of �Modules� for Contracts Use of Voice Technology BethBeth

15. 15 HDR HIM leads a workgroup of subject matter experts, project members and etc to define domain by domain fields that would be considered part of the ehr and assure their inclusion in the HDR. Secondly we are also identifying fields that may not be needed for the EMR but should be retained nationally. ediscovery is part of this discussion BethBeth

16. 16 Practice Brief Updates Legal Record for Disclosure Purposes C&P Fact Sheet Provider to Patient e-mail Lois As many of you now, we have a DRAFT legal record PB. This PB has been developed in conjunction with General Counsel and the privacy office. We are waiting final concurrence from General Counsel, but you should all familiarize yourself with the draft PB and begin to implement the intent. For example all records to Regional Counsel must be grouped in categories, each note on a separate page, and if submitting in paper with section separated and tabbed. If submitting via CD the CD should be formatted in categories and indexed. We are in the beginning stages of developed a fact sheet dealing with C&P issues, how to amend the record, who owns the info, etc. We are working with VBA on this issue and will let you all know when the fact sheet is completed. We are also trying to pull together some information on Provider to Patient e-mail.Lois As many of you now, we have a DRAFT legal record PB. This PB has been developed in conjunction with General Counsel and the privacy office. We are waiting final concurrence from General Counsel, but you should all familiarize yourself with the draft PB and begin to implement the intent. For example all records to Regional Counsel must be grouped in categories, each note on a separate page, and if submitting in paper with section separated and tabbed. If submitting via CD the CD should be formatted in categories and indexed. We are in the beginning stages of developed a fact sheet dealing with C&P issues, how to amend the record, who owns the info, etc. We are working with VBA on this issue and will let you all know when the fact sheet is completed. We are also trying to pull together some information on Provider to Patient e-mail.

17. 17 Mentoring Program Be a mentor! Experienced HIM professionals share their knowledge with newcomers New mentors are always welcome More information the VHA HIM webpage as well as applications to be a mentor or as a newcomer to apply to be assigned a mentor A conference call is held each month which covers various topics such as VERA, employee relations, updates from central office, Hybrid Title 38. A conference call is held each month which covers various topics such as VERA, employee relations, updates from central office, Hybrid Title 38.

18. 18 TCF HIM Intern Program Preceptor Application Process 2006 Class Preceptors and Interns Intern Placement You can currently submit your application to be considered to be a preceptor for the 2008-2010 Intern class. The application process closes 9/11/07. The class will have 10-12 interns. Recruitment for interns will begin Feb 08 with a start date of June 1, 08. Introduce and have stand the 2006 Interns with their preceptor (encourage networking with them this week): Audrey Andrews � Dublin; Ora Clark Kazumi Cornell � Puget Sound HCS; Susan Helbig Marie Howell � Phoenix; Pat Christensen Laura Hughes � Cincinnati; Susan Schehr Jeanette Jackson � Minneapolis; Sandra Sampair Jennifer Kriegel - St. Louis; Joyce Ellison Kim Moses � Birmingham; Phyllis Sullivan Vin Ngo Pham - White River Junction; Sandra Davidson Kelly Rodriguez - Nebraska Western Iowa HCS (Omaha); Mary Adams Rich Van de Plasch - Puget Sound HCS; Susan Helbig Coordinating placement of these interns in to permanent positions will begin around Jan/Feb 08 for the first intern who will be completing their 2 year training in 08. Contact Karla Porter if interested in hiring an intern in to a vacant position. You can currently submit your application to be considered to be a preceptor for the 2008-2010 Intern class. The application process closes 9/11/07. The class will have 10-12 interns. Recruitment for interns will begin Feb 08 with a start date of June 1, 08. Introduce and have stand the 2006 Interns with their preceptor (encourage networking with them this week): Audrey Andrews � Dublin; Ora Clark Kazumi Cornell � Puget Sound HCS; Susan Helbig Marie Howell � Phoenix; Pat Christensen Laura Hughes � Cincinnati; Susan Schehr Jeanette Jackson � Minneapolis; Sandra Sampair Jennifer Kriegel - St. Louis; Joyce Ellison Kim Moses � Birmingham; Phyllis Sullivan Vin Ngo Pham - White River Junction; Sandra Davidson Kelly Rodriguez - Nebraska Western Iowa HCS (Omaha); Mary Adams Rich Van de Plasch - Puget Sound HCS; Susan Helbig Coordinating placement of these interns in to permanent positions will begin around Jan/Feb 08 for the first intern who will be completing their 2 year training in 08. Contact Karla Porter if interested in hiring an intern in to a vacant position.

19. 19 VeHU HIM Sessions Still to Come Today: 167, HIM/Privacy Network News, at 5pm in this same room for open Q&A Wednesday: 104, Policing Your Health Record Forms and Templates 105, Hybrid Made Simple 106, Should Providers Send Patient Info by e-mail? 168H, CAPRI and C&P Exam Templates Karla Many other sessions are being offered this week with in depth discussion on topics we did not include here Karla Many other sessions are being offered this week with in depth discussion on topics we did not include here

20. 20 VeHU HIM Sessions (cont) Thursday: 102, Best Practices for Health Record Recovery and Pre/Post Disaster Planning 201, Computer Applications for Improving Coded and Administrative Data: Implications for Research and Performance Measurement 203, Identity Management � Uniquely Identifying Patients in a Changing Environment 235, VistA Imaging - Document Imaging Policy and Procedure

21. 21 VeHU 2008 Karla This year�s Planning Committee: Shawana Burch, Sylvia Hanna, Richard Reid, Jennifer Rollins Focus Groups will be the week of Sept 24th in Orlando (HIM will be either Wed, Thurs or Fri) � sign up on the VeHU 2007 conference home page to volunteer to be considered (funded). 2008 � posters, speakers (submissions for session topics will be open in the fall � watch for email) Karla This year�s Planning Committee: Shawana Burch, Sylvia Hanna, Richard Reid, Jennifer Rollins Focus Groups will be the week of Sept 24th in Orlando (HIM will be either Wed, Thurs or Fri) � sign up on the VeHU 2007 conference home page to volunteer to be considered (funded). 2008 � posters, speakers (submissions for session topics will be open in the fall � watch for email)

22. 22 QUESTIONS AllAll