Coding Your Encounters in AHLTA

1. Coding Your Encounters in AHLTA Lisa Rosenthal, CCS-P Outpatient Coding Supervisor Naval Medical Center Portsmouth May 2006

2. AHLTA & Coding • AHLTA provides “point of care coding support” • Use of templates and/or AIM forms will ensure the most accurate calculated E&M in AHLTA • Free text documentation and/or scanning of information into an encounter will require the provider to manually over-ride the calculated E&M to avoid under-coding • Codes are linked to all procedures and diagnoses in AHLTA

3. Coding calculations • E&M= Documented HPI +Diagnosis + Patient Status + Service type + Exam type • RVU= E&M + Procedures • AHLTA only allows visualization of E&M code in disposition module before signing off encounter

4. AHLTA & Coding The following slides are provided to help navigate the AHLTA user through the A/P and Disposition screens where the coding of the encounter takes place. Accurate coding is vital to ensure that all services provided are counted and workload is reflected properly. Thorough documentation = accurate coding.

5. The A/P Module Inclusion of common diagnoses and procedures in your templates is preferred. However, you may use Add to Favorite List for common or hard to find diagnoses and procedures that aren’t in your templates. Diagnosis Tab in the AP Module Add diagnoses to personal favorite list by highlighting the code at left and clicking the button below.

6. The A/P Module Procedure Tab in the AP Module. Use to code for procedural services performed by you or your staff. Use the “ORDER” tabs for procedures to be performed in other departments of the hospital, i.e. labs and rads. Some codes, such as Pap collection and injectable meds (B12, Bicillin), must be searched under HCPCS May add procedures to Favorites List as well

7. The A/P Module Ordered Performed Procedures listed above indicate services were performed in your clinic by you or your support staff. These are coded services which generate RVUs. Labs/Rads shown above are services that you have ordered to be performed outside your clinic space.

8. The Disposition Module Your calculated E&M is derived from your templated documentation, the diagnosis, patient status, service type and exam type.

9. The Disposition Module Currently, you must select whether your patient is new or established; future upgrades (838 local cache) will determine the patient status based on previous encounter history. You must still confirm that selected Patient Status is correct.

10. The Disposition Module Select the type of visit: outpatient visit, consult, preventive medicine, etc. 838 version will select for you but you must confirm selected Service Type is correct.

11. The Disposition Module To review what the system counted in your documented HPI, click on the “HPI” button to open the detail window.

12. The Disposition Module To see details of what was counted from your documentation, click any of the headings to open the detail window.

13. The Disposition Module Use the Selection tab to code your visits manually. Click here for the drop-down list of E&M categories. 99499 is selected here for procedure only visits, i.e. injection only, visit for colonoscopy, etc.

14. The Disposition Module Once an E&M category is selected, a list of all available codes appear. Highlight the appropriate code for today’s encounter.

15. The Disposition Module Use the Add’l E&M Coding tab when two Evaluation & Management services are performed on the same day by the same provider. In the example below, modifier -25 is needed with the second E&M service. Be sure to link each E&M service with the appropriate diagnoses

16. The Disposition Module If an E&M is performed on the same day as a procedure, go to the Add’l E&M Coding tab, open the Modifier drop-down window by clicking here and select modifier –25.

17. The Disposition Module The Time Factor section is only used when >50% time is spent counseling or coordinating care. DO NOT USE TO ARTIFICIALLY UP-CODE YOUR VISIT! Use the Comments tab to open the free-text box to document the total visit time + time spent counseling and/or coordinating care. This justifies increased coding value when legitimate. This function only works from the Calculated coding function and does not hold if you leave Disposition module and come back.

18. The Disposition Module AHLTA will calculate the code based on time only when both boxes are checked

19. AHLTA Assistance is Available • Contact your clinic Super User or MTF Clinical Champion for AHLTA assistance • Contact your Coder POC for coding-related questions • Contact your Regional AHLTA Champion for any questions • Submit trouble tickets for known discrepancies

20. CONCLUSIONS • If you DOCUMENT well, AHLTA will code for you • If you don’t document well, you may lose coding credit • If you use alternative methods of input (scanning, pasted documents) you will have to know how to code