Admission/Discharge/Transfer Admission/Discharge/Transfer (ADT), Coding & Error Resolution(ADT), Coding & Error Resolution

RPMS EHR Inpatient

Admission/Discharge/Transfer (ADT)

• Pre-implementation Check-List

• PIMS ADT User’s Manual Jan 2009 ww.ihs.gov

• PCC Supervisor’s Manual www.ihs.gov

• IHS Chapter 3, HIM Manual www.ihs.gov

• Present on Admission Site Parameters (PCC)

Things to Consider…

– Admit/Discharge orders (Date/Time)– Setup ADT Files (System Definition Menu)

• Treating Specialty (OB, NB, GM, PEDS, OBS)• Room-Bed• Ward

– Switch Bed (SWB)– Ward Transfer (WTX) – Attending physician (Change Provider when

there is an order) PCH Provider Change

Things to Consider cont’d…

– Against Medical Advice (AMA), Absent without Leave (AWOL), Patient on PASS

– Discharge from Observation to Admit to acute care (time must be 1 minute after discharge from observation)

– Intra-facility transfers (ward, treating specialty)• There must be an order from the attending

physician to transfer from one ward to another, and from one provider to another provider (SWP)

Things to Consider cont’d…

• Discharge– Time of Discharge (discharge orders and nursing

discharge) – Correct discharge treating specialty (Mnemonic: IP)– Transfer to an IHS or non-IHS facility (build your own

list)– Admission/Discharge Type/Source

• IHS• UB-92

It is important to admit, discharge, and transfer in a timely manner!

Discharge Summary

• PCC Inpatient Supplemental & Discharge F/U Record, IHS-485 (not required)

• D/C Summary Tab v. Dictated DS• Discharge Summary template

– Present on Admission (POA) Parameters• Acute Care v. Critical Access Hospital

– POA (may be added to the template)– Importing data objects into the template (med

list, labs, patient education codes)

POA Parameters UPDATE PCC DATA ENTRY PARAMETERS SITE NAME: DEMO HOSPITAL• ************************************************************************• UPDATE DEFAULT PARAMETERS (press enter): FORMS TRACKING? (Y/N) Y• UPDATE DISPLAY PARAMETERS (press enter): ASK OUTSIDE LOCATION?

(Y/N) Y• Prompt for VISIT CREATION? (Y/N) Y ASK PROVIDER EVENT TIME? (Y/N) • PROMPT FOR MODIFIERS WITH CPT ENTRY? YES PROMPT FOR MODIFIER

ON POV? N• ASK WALK-IN/APPT FOR CLINIC? (Y/N) Y• TYPE OF PROCEDURE CODING: ICD OPERATION CODING• Require Present on Admission (POA) for Hospital Stays? ?

– Choose from:– 1 DO NOT REQUIRE POA - CRITICAL ACCESS HOSPITAL– 0 REQUIRE POA

Present on Admission

Enter PURPOSE of VISIT: HTN

401.9 (HYPERTENSION NOS)UNSPECIFIED ESSENTIAL HYPERTENSION

OK? Y//

PRESENT ON ADMISSION?: Choose from: Y YES N NO U UNKNOWN W CLINICALLY UNDETERMINED 1 UNREPORTED/NOT USED (Exempt Codes)

PRESENT ON ADMISSION?: Y YES

Inpatient A Sheet• 25 Admitting Diagnosis Insurance Coverage• DIABETES II/UNSPEC NOT UNCONTR (250.00•

• --------------------------------------------------------------------------------• 26 ICD9 27 POA 28 Established DX• 250.00 X DIABETES MELLITUS CONTROLLED• 401.9 HYPERTENSION• 496. CHR OBSTRUCTIVE PULMONARY DISEASE•

Coding

– Use of Historical diagnoses (pertinent to the inpatient stay)

– Adding a Diagnosis– E&M codes

• Initial• Subsequent Days (Daily)• Discharge Management• Observation

– Present on Admission Documentation (Coders enter codes/POA Indicators in ADT)

– Final A Sheet vs. A Sheet worksheet– Inpatient Deficiencies

In-Hospital Visits

• Description– A patient seen by a consultant while in the

hospital, e.g., receiving physical therapy treatment during a Hospitalization.

• Link In-Hospital Visits to Hospitalizations (INP)– AUT Link In-Hospital Visits to Hospitalizations– MAN Manually Link In-Hospital to H Visit

TIU and ADT Reports• TIU SSD option should be used to monitor and track incomplete documents

– Unsigned, Signed, by provider, Date range, Progress Notes, Discharge Summaries

• ADT Reports Menu (RM)• Current Inpatient Listings• Provider's Incomplete Charts

• Incomplete Chart Reports (ICR)• Listing of Coded A Sheets• Operators' Inpatient List

• Incomplete Chart Statistics (ICS)• Inpatient Coding Status Report• Incomplete/Delinquent Statistics by Provider

Daily/Monthly Census

• Admissions & Discharges Sheet (ADS)

• Monthly Census (M202) (CEN)

• Yearly Census (Y202) (CEN)

Correcting Errors

• Changing Note Title

• Retracting a Note (Justification documentation)

• Reassign Note

Questions?