EM Auditor Instructional Manual

Transcription

1 Supercoder.com introduced a new audit tool for E/M coding that works in tandem with CMS-1995 & 1997 guidelines and provides user with code-related information as a ready reference. This tool covers all types of services under evaluation and management, Psychiatric and Ophthalmological sections. The interactive tool allows user to choose the specific guidelines he wants to follow and suggests coding tips and official guidelines throughout different sections of key components. Once logged in, a user accesses the home page of the EM Auditor tool which contains lists of audited cases and a button to start a fresh audit. When a new audit is started, user will go through different screens of the tool (7 in total) depending upon the selected type of service. This tool, coupled with unique interactive suggestions and accurate calculation, provides a fast approach toward EM coding/audit service. PATIENT DATA Screen: 1) The tool EM Auditor contains 7 screens which can be seen at top of the screen just below the tool logo. To move from one screen to another, user needs to fill information in current screen, then press Save button (orange color) at top and bottom of screen. System will automatically move to next screen. In some cases, if user does not require to fill information in one screen, he can proceed to next screen by manually clicking the screen name from top part of the page (for example, you can click in Medical Decision Making tab at top part to move to that screen directly. But remember, if data is entered in a screen and Save is not clicked, that info will not be saved by the tool, hence system will not be able to use that data in code level calculation. User can remove all information entered in a screen by clicking Clear button (blue color) at top and bottom of screen.

2 2) Enter the requisite information in Patient Data screen. Mandatory fields are marked with asterisk (*). 3) Date fields can be filled up either using the calendar, or through manual date entry. Dates must be in MM-DD-YYYY format only. 4) Locality field allows auditor to select State where Physician Practice is based, so that tool can display RVU and Fees in $ of the E/M code audit as per state on Final Code Level screen. 5) In audit purpose, fill in the Client Chosen E/M or ED Code field with a code chosen by physician/client.

3 6) The last 2 dropdowns under Type of Service field are mandatory. Choose the specific type of service being audited (office visit/inpatient/ed/complex chronic care/ophthalmologic general exam etc.) from first dropdown, and then choose the sub-type of service (new patient/established patient etc.) from second dropdown. 7) If user wants to code/audit a chart based on time, choose Time Based E/M Service from dropdown, which is highlighted and placed on top of list.

4 8) In several instances, based on type of service selection, system will auto-proceed to time based coding screen or critical care screen or to final code level screen, upon clicking Save button after filling up required information in patient data screen. For example, if Complex Chronic Care Coordination Services is selected from type of service dropdown, system will inform the user about being forwarded to time based coding screen. 9) POS field is supplied with autosuggestions when user puts the first digit in the box. For example, if you are looking for POS 11 (for office visits), put 1 and system suggests the rest. HISTORY Screen: 10) Once user is in History screen, the info entered in first screen (Patient Data) will be seen as ready-reference at top of the tool, in a green bar, and the user-entered code (Client s Code) in blue bar. These two informational bars are available in top and bottom of every screen, except the patient data and final code level screens. 11) Client s Code at green bar at top and bottom of the screen shows the code entered by physician or client (before auditing), and Code field shows the code being generated by the systems based on data elements entered by the user in real-time basis. The system-generated code, if matches with client s code (or a higher code thereby suggesting better level of service), will display in green color with a green flag, whereas if it does not match with client s code, will display in red color with a red flag.

5 12) There are radio buttons and check boxes available within the tool for the user to pick the required data element as per documentation. 13) Level of any key component, including history would be generated instantaneously, at the bottom of each page. The same can be seen near green bar. The level of the key component will change in real time, with the user choosing/changing the data elements. The final level of the key component will be decided when user does not enter any further info and click on save button to proceed to another screen.

6 14) If history or a specific component of History (HPI, ROS or PMFSH) cannot be obtained due to various reasons, check the history is unobtainable box and then check the specific part of History which could not be obtained along with the reason for history being unobtainable. System will calculate the level of history by providing un-obtainable component highest level it can attain. 15) In HPI, ROS and PMFSH sections, either choose the individual bullet elements, or choose no. of elements using radio buttons.

7 16) In all screens of key components, with every header, there are notes entry boxes where auditor can enter coding/auditing notes which can be saved for future reference. Also user can see CMS Guidelines using CMS button. All the notes entered by user in different key comp. sections would be consolidated and displayed in the Final Code Level screen under Specific Notes header.

8 Notes seen in consolidated form in final screen: EXAMINATION Screen: 17) Choose from 1995 or 1997 PE options. Based on user s choice, the particular form will open. 18) Choose the data elements to generate level of PE as per 1995 / 1997 CMS guidelines. For 95 PE, 4 types of exams, (CMS, Noridian, Marshfield, and Novitas) are provided, user can select any type of Exam using Radio-Button and then on selecting data elements, tool will calculate level of Exam.

9 19) Under 1997 PE, there are two tabs Multi-system exam audit and Specialty specific exam audit. Choose the required option and select data elements. There are i symbols available beside few specific systems which will provide coding tips.

10 Under Specialty specific exam audit tab, listing of those Specialty exams will be displayed which are specific to the gender selected on Patient data screen. For male following Exams will be listed: For Female following Specialty Specific Exams will be listed: Under Specialty Specific Exam Audit tab, first select the specific examination

11 and then within it choose data elements. 20) If user has chosen 1997 PE exam type, system will calculate the possible PE level under 95 exam type too, and in case 95 generates a higher level of PE and hence higher level of final E/M

12 code than 97 guidelines, it will prompt the user to decide which exam type (95 or 97) would he want to use, in order to get a better level of final code. If Yes is chosen, system will recalculate the PE accordingly and convert the chart calculation. If No is chosen, user can proceed with already generated level of PE and therefore the same level of code. MEDICAL DECISION MAKING Screen: 21) There are 3 tables in Medical Decision Making screen - Number of Diagnoses or Management Options, Amount and/or Complexity of Data Reviewed and Risk of Complication and/or Morbidity or Mortality. Number of Diagnoses or Management Options: Put the no. of Dx in column B. System will auto-calculate total score in column D. Amount and/or Complexity of Data Reviewed:

13 Select the items from left side check boxes and system will auto-calculate the score. Risk of Complication and/or Morbidity or Mortality: The highest level of risk selected from the table would be considered by the system to calculate MDM. 22) Final level of MDM will be displayed at bottom and top part of the tool.

14 TIME-BASED CODING Screen: 23) If user chooses Time based E/M Service from type of service dropdown in patient data screen, he will be redirected to this screen. 24) Also in other types of services too, user can manually click on time based coding tab at top of the screen to land at that screen. 25) If user selects key components and time both items, and in case level of service generated by time based coding becomes higher than key-comp. based code level, system will generate a prompt asking the user to decide the code level which to go with. Based on user s selection of Yes or No, the final level of code would be generated by the tool. 26) If Time based E/M Service from type of service dropdown in patient data screen is selected, in the time screen user can see two dropdowns from where he can select the exact type and subtype of service.

15 27) Depending on the selection, user can enter the face-to-face or on-floor time and the system will calculate the level of code based upon the amount of time entered. 28) If one of the criteria for time based coding is NOT met, system will re-direct the user to history screen for key component based coding. CRITICAL CARE SERVICES Screen:

16 29) If chosen type of service in patient data screen is Critical Care Services, system will re-direct the user to Critical Care Services screen. In that screen, enter the time exclusive for critical care service. System will calculate the final code based on time entered. The screen enlists the services/procedures that are NOT to be reported separately if performed by the same physician during critical care service provision. FINAL CODE LEVEL Screen: 30) This screen consolidates all the information that has been entered by the user in various screens while performing the chart audit. 31) Levels generated by the tool in various key component levels will be populated. 32) User has the option to enter the diagnosis codes (max. four) too in this screen. 33) Field client s code code entered by physician, if available. 34) Field reviewer s code EM code generated by tool. 35) Field RVU Difference/Fee Difference the difference between non-facility RVU and Fee in $ of client s code and that of reviewer s code. This will help the user to estimate the amount of overcoding or undercoding and the subsequent impact on revenue. As given for Physician code.

17 36) Supercoder users can access the ICD-9-CM & CPT codes detail pages from this tool, based on the codes entered or generated in this tool. Short descriptors of the diagnosis and procedure codes link directly to Supercoder code pages, thereby providing easy access to code, article and coding tools references to the user (depending on user s level of access in Supercoder).

18 37) At the bottom of Final code level screen, the User Notes area can be used to enter coder or auditor s notes for future reference or for educational purpose. 38) Once a case is completed, user can click Save and Finish button. System will save this case in audit list page (the page containing all of user s previously audited cases). The Print button at the right-most area can be used to generate a PDF to store or print. 39) When a case is saved, a blue colored button named Go To Audit Listing Page will appear which will lead the user to audit list page to start a fresh case audit or to select and revisit an already completed case. 40) At audit list page, click on Start New Audit button in order to start a fresh case. Else, the user can revisit an already completed case by clicking on Modify link beside corresponding case. 41) You can also check the PDF (of an already completed case) automatically saved at audit list page. 42) You can also filter the list of audit cases from the existing list by selecting specific data as parameter.

19 43) By clicking Modify link, user can re-visit a case, can review the data elements chosen, and if required can alter the data elements selection. The system will modify the level of key components or final level of service code based on altered information. Therefore a user can come back to a case and change the outcome as per requirement.