Coding Your Encounters in AHLTA

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Coding Your Encounters in AHLTA

• Lisa Rosenthal, CCS-P
• Outpatient Coding Supervisor
• Naval Medical Center Portsmouth
• May 2006

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AHLTA Coding

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

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Coding calculations

• EM Documented HPI Diagnosis Patient Status
  Service type Exam type
• RVU EM Procedures
• AHLTA only allows visualization of EM code in
  disposition module before signing off encounter

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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.

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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 arent 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.
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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
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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.
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The Disposition Module
Your calculated EM is derived from your
templated documentation, the diagnosis, patient
status, service type and exam type.
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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.
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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.
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The Disposition Module
To review what the system counted in your
documented HPI, click on the HPI button to open
the detail window.
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The Disposition Module
To see details of what was counted from your
documentation, click any of the headings to open
the detail window.
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The Disposition Module
Use the Selection tab to code your visits
manually.
Click here for the drop-down list of EM
categories.
99499 is selected here for procedure only visits,
i.e. injection only, visit for colonoscopy, etc.
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The Disposition Module
Once an EM category is selected, a list of all
available codes appear. Highlight the
appropriate code for todays encounter.
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The Disposition Module
Use the Addl EM 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 EM
service. Be sure to link each EM service with
the appropriate diagnoses
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The Disposition Module
If an EM is performed on the same day as a
procedure, go to the Addl EM Coding tab, open
the Modifier drop-down window by clicking here
and select modifier 25.
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The Disposition Module
The Time Factor section is only used when gt50
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.
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The Disposition Module
AHLTA will calculate the code based on time only
when both boxes are checked
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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

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CONCLUSIONS

• If you DOCUMENT well, AHLTA will code for you
• If you dont 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