Healthcare Common Codes Solution

Transcription

1 Healthcare Common Codes Solution Version 3.2 SP1 Business Use Case Guide

2 Copyright 2013 Pegasystems Inc., Cambridge, MA All rights reserved. This document describes products and services of Pegasystems Inc. It may contain trade secrets and proprietary information. The document and product are protected by copyright and distributed under licenses restricting their use, copying distribution, or transmittal in any form without prior written authorization of Pegasystems Inc. This document is current as of the date of publication only. Changes in the document may be made from time to time at the discretion of Pegasystems. This document remains the property of Pegasystems and must be returned to it upon request. This document does not imply any commitment to offer or deliver the products or services described. This document may include references to Pegasystems product features that have not been licensed by your company. If you have questions about whether a particular capability is included in your installation, please consult your Pegasystems service consultant. For Pegasystems trademarks and registered trademarks, all rights reserved. Other brand or product names are trademarks of their respective holders. Although Pegasystems Inc. strives for accuracy in its publications, any publication may contain inaccuracies or typographical errors. This document or Help System could contain technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Pegasystems Inc. may make improvements and/or changes in the information described herein at any time. This document is the property of: Pegasystems Inc. 101 Main Street Cambridge, MA Phone: (617) Fax: (617) Healthcare Common Codes Solution Document: Business Use Case Guide Software Version: 3.2 SP1 Updated: August 2013

3 Contents Preface... 2 Intended Audience... 2 Guide Organization... 2 Chapter 1: Healthcare Common Codes Solution Overview... 3 Business Overview... 3 Key Features of the Healthcare Common Codes Solution... 4 Using and Creating Code Sets & Code Groups... 4 Code Sets... 4 Code Groups... 5 Chapter 2: Code Set Technician Portal Use Cases... 6 Use Case 1: Searching for Code Sets... 6 Use Case 2: Managing Code Sets... 8 Use Case 2.1: Reviewing Code Sets... 8 Use Case 2.2: Editing Code Set Metadata... 8 Use Case 2.3: Adding Codes Use Case 2.4: Filtering Codes Use Case 2.5: Editing in Excel Use Case 2.6: Uploading Code Files Creating a Custom Code Set Use Case 2.7: Accessing Audit Trail, Attachments and Notes Chapter 3: Code Group Manager Portal Use Cases Configuration Settings for Code Groups Use Case 1: Managing Code Groups Use Case 1.1: Creating Code groups Use Case 1.2: Modifying Code Groups Use Case 1.3: Creating a Copy of a Code Group Use Case 1.4: Accessing Audit Trail, Attachments and Notes Use Case 2: Searching for Code Groups Chapter 4: Code Approval Manager Portal Use Cases Use Case 1: Approving a Code Group

4 Preface This guide is designed to provide you with an overview of the Healthcare Common Code Solution (the Solution), including business use case to aid in the searching, managing, loading, and creation of Code Set and Code Groups. Intended Audience This guide is intended for business and technical users and provides use cases which demonstrate the Healthcare Common Code Solution functionality. Guide Organization This guide contains the following chapters: Chapter 1: Healthcare Common Codes Solution Overview Chapter 2: Code Set Technician Portal Business Use Cases Chapter 3: Code Group Manager Portal Business Use Cases Chapter 4: Code Approval Manager Portal Business Use Cases Provides an overview of the Healthcare Common Codes Solution Provides instructions for: searching code sets managing Code sets loading code sets creating custom code sets Provides instructions for: Configuration settings for code groups searching code groups managing Code groups Provides instructions for: approving a code group rejecting a code group sending a code group back to the originator for more information 2

5 Chapter 1: Healthcare Common Codes Solution Overview Business Overview There are several levels of interpretation that must occur to create a traceable and auditable translation layer from healthcare codes (CPT, ICD-9, Specialty, etc), that are submitted on claims, to common healthcare terms such as Office Visit, CABG Cardio Bypass Graph or Medically Necessary. These terms can be mapped to Benefits such as Mental Health and Substance Abuse Treatment as well as used for other business functions like care management. There are four steps in this process: Entry and maintenance of healthcare codes sets Grouping of codes to basic Code Groups Logically connecting code groups to form Healthcare Terms Logically mapping Healthcare terms to PCS Benefits The chart below describes the relationship between these 4 steps. 3

6 Key Features of the Healthcare Common Codes Solution The Solution described in this document addresses the creation and maintenance of healthcare codes and the code groups (the bottom two components described in the above graphic). The Healthcare Terms and Benefit Set concepts are managed in the Product Composer framework that leverages this Solution as part of the Healthcare Industry Foundation. The key features include: Manage commonly used healthcare code sets Manage custom code groups to support business objectives such as creation and management of benefit terms and definitions Using and Creating Code Sets & Code Groups Code Sets The Healthcare Common Codes solution supports the following code set types. Additional code set types can be created as needed. Bill Type CPT DRG GCN HCPCS ICD9 Diagnosis ICD9 Procedure ICD10 Diagnosis ICD10 Procedure Modifier NDC Place of Service Provider Taxonomy Revenue The solution contains SAMPLE codes for each of these sets except the following proprietary code sets. It is expected that Pega s customers use their licensed code sets to populate the database tables shipped with the Solution. CPT 4

7 DRG HCPCS ICD9 Please follow the steps mentioned in the Use Case 2.6: Uploading Code Files to load your licensed versions of the code sets to the corresponding database tables. Code Groups The solution provides a Code Group Manager Portal that provides the ability to create and maintain custom code groups. Once the Code Sets have been established and the corresponding data tables have been populated with code set data, you can build the Code Groups as outlined later in this document. 5

8 Chapter 2: Code Set Technician Portal Use Cases This chapter contains business use cases to aid in searching sample code sets; managing code groups; mapping diagnosis and procedure codes; loading sample code sets; and creating your own code set data. Use Case 1: Searching for Code Sets Use Case 2: Managing Code Sets Use Case 2.1: Reviewing Code Sets Use Case 2.2: Editing Code Set Metadata Use Case 2.3: Adding Codes Use Case 2.4: Filtering Codes Use Case 2.5: Editing in Excel Use Case 2.6: Uploading Code Files Use Case 2.7: Accessing Audit Trail, Attachments and Notes Use Case 1: Searching for Code Sets This functionality performs a search of select code sets using specific search criteria and displays the results. Steps: 1. Login to the Code Set Technician Portal using: User Name: CodeSetTechnician@PegaHealthCodes Password: install 2. Click Search Code Set on the top right corner of the Code Set Technician Portal. The Search Code Set dialogue box displays: 6

9 3. Select the CPT radio button and enter a code or description in the Search for field. 4. Click Search to display the results. 7

10 Use Case 2: Managing Code Sets This functionality allows you to: review codes edit code set metadata add single codes filter codes edit multiple codes using Excel upload code files accessing audit trails Use Case 2.1: Reviewing Code Sets Steps: 1. Double click on any code set listed in Code Explorer (left panel). 2. The code set selected opens in a new tab on the right side of the Review screen. Here you can edit code set metadata, add single code, edit multiple codes in Excel and upload code files. Use Case 2.2: Editing Code Set Metadata Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set. 2. Click the Edit link in the header of code set Review screen. 8

11 The Edit Code Set dialogue box displays: 3. Update the description and click Ok to reflect in the code set header. 9

12 Use Case 2.3: Adding Codes Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set 2. Click Add Code on the Review screen. The Add Code dialogue box displays: 3. Add a new code and click Ok to save your entries. Use Case 2.4: Filtering Codes Filtering codes for a specific code or description either exact or wild search criteria. 10

13 Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set 2. From the Review screen enter 00.0 in the Filter field and click Filter. The filter results display in the bottom panel of the Review screen. 3. Enter Therapeutic in the Filter field and click Filter. The filter results display in the bottom panel of the Review screen. 11

14 4. To view a complete list of codes click Clear. Use Case 2.5: Editing in Excel Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set. 2. From the Review screen click Edit in Excel. 12

15 3. When prompted click Enable Macros. 4. An Excel spreadsheet opens loaded with codes from the code set type selected in Use Case 2.1: Review Code Set. The Import Status column contains a status of Refreshed. 13

16 After the code data is modified, the Import Status changes to Modified. 5. You are prompted to permanently update the modified records, click Yes. 14

17 Troubleshooting Instructions: 1. When the server response time out is set to 120 seconds and loading data in excel taking beyond 120 seconds, then users will be prompted to extend that time in order to load large sets of data. 15

18 After 120 seconds, click Yes to increase the timeout by 50% (180 seconds). 16

19 Use Case 2.6: Uploading Code Files Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set. 2. From the Review screen select the Code File tab. 3. Browse to a code file you want to upload and click Upload. For more information on all code file formats, refer to the Healthcare Common Codes Solution Supported File Formats document included on your media. 4. After the code file has been successfully uploaded click Submit to save the uploaded codes. 17

20 A confirmation screen displays: Creating a Custom Code Set To configure custom code set, the following rules have to be created or modified. The following rules are required. Rule Type Name Details Data Class PegaHealth-Codes-Data-XXXX Create a data class that extends the abstract class PegaHealth-Codes- Data-. Create the necessary properties. 18

21 DB Table <database table name> Create a table in the database Database Table mapping <PRPC database mapping rule> Map the data class to the DB table using an instance of Data-Admin- DB-Table Parse Delimited Decision Table Decision Table Name space: ParseCode Record Type: ParseCode GetCodeSetClass GetCodeSetDateFormat Create parse delimited rule, in lines with the format of the incoming data in the code set file. UPDATE this decision table by adding a row, to return the code set class. UPDATE this decision table by adding a row, to return the format of the effective and expiration dates in the codes. Property CodeSetType UPDATE this property, present in the code set work type PegaHealth- Work-CodeSet, to have the appropriate value and label for the custom code set. The following rules are optional depending on the desired additional functionality like adding, deleting, or saving edited codes. Rule Type Rule Name Create or Details Update Activity AddSingleCode Create Create this activity in the code set data class, which sets the properties of the new code. (Refer to the activities, with the same name, in other code set classes) Activity DeleteCode Create Create this activity in the code set data class, to delete a single code. (Refer to the activities, with the same name, in other code set classes) Activity SaveEditedCode Create Create this activity in the code set data class, to update an existing code. (Refer to the activities, with the same name, in other code set classes) List View AllCodes Create Create a List View in the Code set class, to fetch the codes from the 19

22 Activity Section Work-.OpenDefaults ReviewAllCodes_X XXX Update Create DB. (Refer to the List View, with the same name, in other code set classes) Add a row in this activity, to get all the codes from the db, using the list view AllCodes. The page which holds the codes has to be unique, as it will be used for display the codes on the UI. Create a section with repeat Grid layout to show the codes fetched using the OpenDefaults activity. Section ReviewAllCodes Update Include the section ReviewAllCodes_XXXX, to show conditionally, when the CodeSetType is the custom code set. Section ReviewListCodes Update Include the section ReviewAllCodes_XXXX, to show conditionally, when the CodeSetType is the custom code set. Activity PrepareForEditabl edisplay Update Update this activity to create a page, which is used to show the parsed codes. (Refer the other steps, which are created for other code sets) List EditList Create Create a list rule, with the properties of the code set. This rule will be used during Edit in excel. (Refer to List rules, with the same name, in other code set classes) Data Transform RemoveCodeListPa ges Update Update to remove the Page that has the codes of the codeset. This page was created in PrepareForEditableDisplay and OpenDefaults activities. Activity ParseCodeSet Update This is the main activity that handles the parsing. If the custom code has any other dates, apart from effective and expiration dates, edit the java step (with label Format the Dates ) in this activity. Control OpenWO Update Update the this control, which displays the label for the codes et 20

23 Use Case 2.7: Accessing Audit Trail, Attachments and Notes Steps: 1. Repeat the steps in Use Case 2.1: Review Code Set. 2. From the Review screen select View History from the Actions drop-down list. The History dialogue box displays containing all the events and operations performed by the system or user, including attachments and notes. 21

24 Chapter 3: Code Group Manager Portal Use Cases This chapter contains business use cases to aid in searching sample code sets; managing code groups; mapping diagnosis and procedure codes; loading sample code sets; and creating your own code set data. Use Case 1: Managing Code Groups Use Case 1.1: Creating Code Groups Use Case 1.2: Modifying Code Groups Use Case 1.3: Creating a Copy of a Code Group Use Case 1.4: Accessing Audit Trail, Attachments and Notes for Code Groups Use Case 2: Searching for Code Groups Configuration Settings for Code Groups Note: An Open Rule Set version MUST be available to create and maintain custom code groups. To be able to create and maintain custom code groups, the system requires an open rule set version configured and available in your application rule set stack. The specified rule set version MUST have the highest version of the PegaHealthCodes as it s pre-requisite. Steps: 1. Login to the system using: User Name: Administrator@PegaHealthCodes Password: install 2. Click on the icon on the portal and navigate to Healthcare > Configuration. 22

25 3. Specify the Rule set and Version of the open rule set where you chose to store the custom code group rules. Click Save. 4. Ensure the rule set version specified above has the highest version of PegaHealthCodes rule set as it s pre-requisite. 23

26 Use Case 1: Managing Code Groups This functionality allows you to: create a code group modify a code group create a copy of a code group accessing audit trails, attachments, and notes Use Case 1.1: Creating Code groups Steps: 1. Login to the Code Group Manager Portal using: User Name: CodeGroupManager@PegaHealthCodes Password: install 2. From the homepage Get Started section click Create Code Group. The The Code Group screen displays: 24

27 3. On the Enter Metadata tab complete the following fields and click Next>>. Name Purpose Effective Date Expiration Date Description The Select Codes tab displays: 25

28 4. Select the Code Set type, enter a Code range and click Next>>. The Review and Submit tab displays: 5. Review your modifications and click Submit. 26

29 The code group status changes form Resolved-Available to Pending- Approval and the Code Explorer displays only the approved code groups. 6. After a code group status is changed to Pending-Approval the Code Group Manager can perform a self-approval by clicking on the assignment or an operator can approve/reject. 27

30 Use Case 1.2: Modifying Code Groups Steps: 1. Open an approved code group from Code Explorer. 2. Click Modify Codes. The Code Group screen displays: 3. Edit/modify the already configured code sets, and click Next>>. 4. The code group status changes form Resolved-Available to Pending- Approval and the Code Explorer displays only the approved code groups. 28

31 5. After a code group status is changed to Pending-Approval the Code Group Manager can perform a self-approval by clicking on the assignment or an operator can approve/reject. 29

32 Use Case 1.3: Creating a Copy of a Code Group Steps: 1. Open an approved code group from Code Explorer. 2. Click Create a Copy to open the Code Group screen along with prepopulated data carried from the existing the code group. 30

33 3. On the Enter Metadata tab change the following fields (as necessary) and click Next>>. Name Purpose Effective Date Expiration Date Description Note: Be sure to change either the code group name or effective date to avoid conflict. The Select Codes tab displays: 31

34 4. Select the Code Set type, enter a Code range and click Next>>. The Review and Submit tab displays: 5. Review your modifications and click Submit. 32

35 The code group status changes form Resolved-Available to Pending- Approval and the Code Explorer displays only the approved code groups. 6. After a code group status is changed to Pending-Approval the Code Group Manager can perform a self-approval by clicking on the assignment or an operator can approve/reject. Use Case 1.4: Accessing Audit Trail, Attachments and Notes Steps: 1. Open an approved code group from Code Explorer. Select Actions View History 2. From the Actions drop-down list select View History. The History dialogue box displays containing all logged events. 33

36 Use Case 2: Searching for Code Groups This functionality performs a search for a select code group using specific search criteria and displays the results. Steps: 1. Login to the Code Group Manager Portal using: User Name: CodeGroupManager@PegaHealthCodes Password: install 2. Select Search >Code Group from the top right corner of Code Group Manager Portal. The Search Code Group dialog box displays: 34

37 3. Select a Code Group Category and enter a code group name or description in the Search for field. Acceptable search criteria includes: Exact or wild card for code group name/description Exact or wild card for code 4. Click Search to display the results. 35

38 Chapter 4: Code Approval Manager Portal Use Cases This chapter provides the details for approving or rejecting a code group. Use Case 1: Approving a Code Group Use Case 1: Approving a Code Group Steps: 1. Login to the Code Approval Manager Portal using: User Name: CodeApprovalManager@PegaHealthCdes Password: install 2. Select Code Approval Manager in the left panel under Health Codes Default Work. The screen populates with a lists of code groups that require approval. 36

39 3. Select one of the code groups to open the Code Group screen. 4. Refer to the following table for you next action: Click Approve Reject Send To Originator To change the code group status to Resolved-Available change the code group status to Resolved-Rejected send the code group back to the originator for more information 37