PRESENTATION ON AHLTA How to make AHLTA work

PRESENTATION ON AHLTA: How to make AHLTA work for you! Introducing the “Usability AIM” Possibly the only AIM you’ll ever need! Anthony Inae M. D. tony@inae. net March 24, 2008

Goals for the Presentation You will learn how to: 1. Document quickly, easily and effectively 2. Receive appropriate credit for what you do 3. Go home on time

Outline p p p Speed up Windows Core Templates How an E&M code is determined How RVU’s are determined The Usability AIM Form Adding the Usability AIM Form to you’re my Favorites List

Speed up Windows XP by turning off Visual Effects

Turn off Autosave and Auto. Print User Preferences p You can get to this options box by clicking “options” while in the SO module

Core Templates Keep Favorites List of Templates to a Minimum Core Templates You Need, nothing more, nothing less… 1. Default Template (*list template) 2. **Well Visit Templates 3. Procedure Templates 4. The 80% Template 5. Most commonly seen Diagnoses (several times per day) Templates (optional) Items not on an AIM Form + A/P Items Ex. “Usability AIM” Form Ex. Cold (URI) Template Delete or remove everything else * List template for S/O Medcin terms. Personal preference. AIM Form attached to default template takes longer to load. ** Ex. Well Woman (Pap), School, Flight, PHA and General Physicals, Pediatric Well Visits, etc…

How an E&M Code Is Determined Basics of an Outpatient Visit The visit is made up of 3 components: [1] Patient History p History of Present Illness (HPI) p Review of Systems (ROS) p Past Family Social History (PFSH) [2] Physical Examination [3] Medical Decision Making p Diagnosis/Management Risk p Complexity of Data p Problem Risk p Test Risk p Management Risk For Established Pts 2 of 3 components are required to meet the level for that visit. For New Pts All 3 are required

How RVU’s are Determined A provider’s RVUs are determined primarily by 2 components n n Evaluation and Management Code (E&M) Procedures (CPT and HCPCS codes)

Sample E&M RVU Numbers p p p New vs. Established (more points for new patients) Primary Care and Family Practice are DIFFERENT clinics. E&M Codes New/EST n n n n 99212 (Prob Focused) 99213 (Expanded Prob Focused) 99214 (Moderate Complexity) 99215 (High Complexity) 99381/91 (Prev Med 0 -1 yo) 99382/92 (PM 1 -11 yo) 99385/95 (PM 18 -39 yo) 99386/96 (PM 40 -64) 0. 45/0. 45 RVU 0. 88/0. 67 RVU 1. 34/1. 10 RVU 2. 67/1. 77 RVU 1. 19/1. 02 RVU 1. 36/1. 19 RVU 1. 53/1. 36 RVU 1. 88/1. 53 RVU

What About Procedures? p p Correct documentation of procedures are ESSENTIAL! Procedure RVU’s are added to the E&M code Ex: Visit for impaired hearing (E&M 99213 RVU = 0. 67) + ear wax removal (RVU = 0. 61). TOTAL = 1. 28 RVU IMPORTANT: Providers can receive credit for procedures done by ancillary staff.

What About Procedures? A Properly Coded Well Woman Exam can yield big RVU’s: n E&M Prev Med visit (99395) = 1. 36 RVU Procedure: Screening Pap Smear (HCPCS Q 0091) = 0. 37 RUV, n 1. 73 RVU for a 30 minute appt. n

Sample Procedure RVUs p p p Circumcision Ear Wax Removal Excision of Skin Tags I&D Abscess Punch Biopsy IV Fluid, 1 hour Nebulizer Treatment EKG Reading Cryotherapy of skin Screening Pap by Physician IM/SC Injection Oxygen Sat Reading 1. 81 RVU 0. 61 RVU 0. 77 RVU 1. 17 RVU 0. 81 RVU 0. 17 RVU 0. 32 RVU 0. 17 RVU 0. 76 RVU 0. 37 RVU 0. 17 RVU 0. 04 RVU

Preventive Medicine Visits 1) There are different E&M codes for preventive medicine visits (well woman, well child). 2) These visits usually result in more RVU’s and assume a comprehensive history and physical. These are age based which CHCS II does automatically calculate 3) Again, you have to manually select this, by selecting PREV MED EVAL/MGT from drop down menu. A 99214 (Outpt visit, existing patient) = 1. 1 RVU A 99395 (Prev Med visit, existing patient) = 1. 36 RVU A 26% RVU increase!!!

The “Usability AIM” I highly recommended to NOT add this to your Default Encounter Template. Will take too long to load Step by step instructions on adding it to your My Favorites List is described at the end of this presentation. As long as you just add (not save) it to your favorites, it will auto-update automatically when changes are needed. As opposed to copying it and saving it as your personal AIM template. Please check periodically for updated versions by searching “Usability” periodically, and adding in the most recenty dated Usability AIM Form (as described at the back of this presentation)

Use the HPI/Screening Tab for Chief Complaint and past history, family history, and social history

Can type Chief Complaint here. You may indicate you reviewed allergies by clicking here

Rules for HPI. Up to 3 elements for a Brief, and an Extended HPI (99214 level) consists of at least 4 of 8 elements from the list. Tip: Remember DSMA: D = Duration S = Severity M = Modifying Factors A = Associated Sx’s DSMA Makes sense on every patient with a chronic disease. And easily done on all visits. Ex 1. Extended HPI: Diabetes for 6 years. He is on oral medications. He is taking his medications, exercising and watching his diet. He has no numbness or tingling in his feet or legs. Ex 2. Extended HPI: Patient complains of dull ache in right ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and Tylenol. Note: 95/97 coding guidelines say your staff can enter this for you.

If you click this button, you will see the additional coding step required in the disposition section if you use free text to document your HPI.

Clicking that button shows you that if you use free text in your note, and you covered 4 of 8 elements, you need to select the 2 button under HPI in the disposition section and Choose the “With user overrides” button to get the proper code. Note: Only needed if you believe the E&M Code should be a 99214 or above. This step not needed for a 99213.

Use this box to free text your entire HPI. A nice reminder here that to get a new line while typing in any free text box on an AIM Form, Use: CTRL + Enter.

You can click these boxes to indicate you reviewed the patient’s past history, or you can click them to free text these items. Only one of these boxes must be clicked for a 99214 level exam on established patients. On a New Patient, must check all three (PMH, Soc Hx and Family Hx). Should be a clinically pertinent review item to count.

As you use the bar to scroll down this tab you can get to other areas to enter historical information and JCAHO information. You or your screeners (hint) can address these items for you.

Other information on history can be entered here.

Addressing Tobacco and/or Alcohol here gives 1 credit point to Social History… WARNING: on these boxes. Only single click to enter numbers. Do not double click here. It will lock. If it locks, press the “tab” key 14 times, then press enter. If you lose count, alternate between “tab” and “enter” until the mouse frees up. Working to fix this in an updated version. Specific social and Female history

Scroll up to the top of this page and click the ROS tab.

Coding rules are listed at the top. 1 for Problem Pertinent. 2 -9 ROS must be covered for a 99214 (Extended level ROS) from 2 or more different organ systems, etc. Must be clinically important to get credit!

You can free text ROS in this box if you want to self code. To get credit for the constitutional system under ROS you can click N and free text, or you can click N to any of the other specific terms under the constitutional ROS.

HPI / ROS Flip for Readability If you wanted to use this form to document Abnormal HPI findings (i. e. need to click Y), and free text any further data. Then click the ROS button to flip this to an HPI item. This puts the abnormal finding and free text in the HPI section for better readability of the note. Note: AHLTA 3. 3 will optionally flip this automatically

May scroll down to document more ROS. All main systems are covered.

Additional ROS. Note: the musculoskeletal tabs on this AIM form has more comprehensive musculoskeletal ROS.

Additional ROS Click the ‘PE’ tab to go to the physical exam

The top of the physical exam tab has coding reminders (Remember 1, 6, 12 and 18 corresponds to a 99212, 3, 4, and 5) Ex. The detailed level (99214 level) requires 12 bullets from 2 or more body areas. Must be clinically relevant to count!

Use the quick entry ‘Normal’ buttons to annotate that all findings listed to the right are normal.

Clicking Reviewed here will check all of the following vital signs as reviewed. The same applies to all other buttons labeled ‘Normal’. Clicking these square boxes opens up free text for free text entry.

The number next to the Body system listed shows you how many physical exam bullets you get for clicking each ‘Normal’ button

If you didn’t examine of the findings listed, or one of the findings was not normal, you can click on the ‘X’ next to the finding to remove it.

Click ‘OK’ and the finding will be removed. Note: this extra step is removed from AHTLA 3. 3

Thyroid is no longer checked.

Scroll down to document abnormal findings or just more findings.

A more comprehensive physical exam is possible in this section. The number next to the body area tells you the maximum number of physical exam bullets you can get in each section. To get a physical exam bullet, check one or more findings under a bolded term. Note: Checking NL Conjunctiva, NL Sclera, and NL Eyelids gives you 1 for the eye. But, NL Sclera and NL Optic Disc gives you 2, etc.

Scroll down for more physical exam options. Anything that doesn’t give you coding credit will be annotated. Here sinus tenderness does not give coding credit.

A more thorough heart and lung exam is possible here (with several PE bullets).

A very basic musculoskeletal exam is possible here, but we recommend you use the musculoskeletal specific tabs (tabs at top).

Gender specific findings will be “grayed out” and not selectable based on patient gender. Ex. Male specific findings will be “grayed out” and not selectable for a female patient.

Findings that were already selected with the quick entry tab will not be selectable in the complete PE (see lymph nodes above). Also note Cerebellar exam is a non-count.

Don’t forget to scroll up once you have completed your physical exam if you want to use other tabs, otherwise you may see blank on the next tab (just scroll up).

The musculoskeletal (upper) tab has several options for documenting both ROS and physical exam findings.

If you want to document a back exam, click the double arrow next to Neck/Back/Spine/Pelvis.

The tab will open up into a review of systems and a physical exam. The ROS here helps you document your “Red Flag” items from your low back pain evaluation.

One can document c-spine, thoracolumbar spine, pelvis and a full back exam.

Clicking the ‘Normal Back Physical Exam’ bar will auto neg the back exam findings. This will yield 6 PE elements.

The Shoulder tab also has the auto neg function for just the PE, not ROS. Can click Auto Normal Right and Left sides separately.

A maximum of 4 bullets for PE coding from the right and left shoulder, separately. One or more findings from each colored section gives one bullet. Note: If you examine the bad side, ok to examine the good side for comparison, yielding 8 bullets.

Musculoskeletal (lower) has these options.

The knee exam is much like the shoulder with Auto. Normal and 4 PE bullets per side

Well Woman Tab: History

Auto. Neg will Mark Everything on the Exam as Normal. Note: If Rectal exam not done, you must remove each finding by pressing the ‘N’ to remove the findings. Well Woman Tab: Physical exam

A tab to document GXTs, EKGs, & PFTs. Click the box with arrows next to the procedure you are interested in documenting.

Edit by filling in the blank lines and other needed information for a GXT procedure note.

The ‘Other procedures’ tab allows one to document many procedures.

Some example procedures

Disposition Screen Reminder Using free text on the HPI of this AIM form may result in only getting credit for 1 HPI element in the disposition screen.

If you’ve covered at least 4 of the 8 listed elements under HPI, then you should click the ‘ 2’ button under HPI in this screen. To put it another way… If the visit should be a level 4 or higher, you must manually select the ‘ 2’. But… If the visit is a level 3, it is not necessary to change this, because it is already a level 3 (see below).

If selecting the ‘ 2’ under HPI is enough to give you a level 4 E&M, you will see the 99214 listed under ‘With User overrides’.

You must click the button next to ‘With User overrides’ to capture a 99214 for your code. This is done because the HPI calculator in AHLTA cannot read your free text HPI.

Add the Usability AIM form to you’re My Favorites list of templates. Note: Once familiar with use, please try to clean up and remove all the old templates you will not be using. Less is more. This AIM can replace many of your current templates.

You will see the correct AIM Form, AMEDD – RLE – 080323. Due to difficulty in versioning control, always make sure you save the most Recent Dated Usability AIM Form. Date Format above is YYMMDD

Right click and select ‘Add to Favorites’

Then, you should see it listed in My Favorites. Note that it should say (Department of Defense) at the end of the template name.

End

Other Misc. Tips

Keeping things simple p p p Remove all unused templates Have a Default Template Have ‘Well Visit’ templates (i. e. pap / physical exams) Only most commonly used Disease templates Have Procedure templates Have the mother of all AIM forms (Usability AIM) that may do double & triple duty Use Default template and Dx Prompt for everything else you see Avoid drilling down the tree Don’t bounce between modules Don’t fight the system Don’t take things personally

Team Documentation Use of Clinic Favorites for Support Staff p Most common list of Diagnoses (ex. Normal Pelvic Exam…) n p Use them to add Agreed Upon Routine Visits as a verbal order Most common list of Procedures (Think RVU’s) n Use them to add Agreed Upon Procedures as a verbal order

Team Documentation Single Order set for Support Staff p PAP, KOH, Wet Prep, GC/CT, Rapid Strep, Throat Cx, UA, etc. p They may be able to order these in AHLTA as standing orders It may be possible for your support staff to complete all of this for you EXAMPLE ONLY

Default Encounter Template p p Have a Default Encounter Template A template one can set to load for every patient, every encounter automatically to pre-stage n Avoid adding AIM forms to your Default Encounter Template p n n n n n p p Loading is delayed every time you enter S/O – it will slow you down! Most commonly used MEDCIN items (not on your AIM form) Not created to be Auto. Neg. Able Procedure notes (canned text blurbs) Diagnoses (only your most common and hard to find) Procedures (possibly all the CPT codes you use) Labs (possibly all the most commonly used by you) Meds (only the most common, if at all) Radiology (only the most common) Otherapies (patient education documentation) Use for documenting all other visits that don’t have a template May be used in conjunction with Dx. Prompt

General Workflow Documenting Note in AHLTA Complete A/P First See Your Patient (Add Dx First, then Add Orders) Did Support Staff Yes No Complete the Subjective For Me? Take Over Note ‘Edit -> No -> Yes’ Do I have Yes New No A Template? Disease Specific List Template AIM Forms Default Template (List Template) 1. Load the Template * 1. Disease Specific 2. Free text Visit For: 2. Well Child (Ages) 3. ROS Tab - Flip to HPI Abnormals 3. OB Intake 4. Auto. Neg (Deselect what you did not ask) 4. Usability AIM 5. PE Tab - Click Abnormals 5. Etc. 6. Auto. Neg (Deselect what you did not examine) 7. Free text anything else on physical. * For Multiple Problem Visits (I. e. DM, HTN, Hypothyroid) - If you have a template, choose the 1 most comprehensive, then free text the rest - If you do a Dx. Prompt, only Dx. Prompt Once - on the most comprehensive, I. e. DM gives terms that can be used to document HTN and Hypothyroid, etc. With Dx. Prompt Disposition & Sign Sip some Coffee Usability AIM Form Consider Dx. Prompt See Next Patient Or Go Home Early

Copy / Paste p p p “CTRL C” and “CTRL” V are your friends Right clicking (copy / paste) not always an option Useful for X-Ray comments, Consult reasons, A/P comments to be reused in “S/O Visit For” to document what you just typed then edited down CTRL C = Copy CTRL V = Paste

Adding Cell Phone # Demographics Comments p p p Cell phone number here Temporary Address here Does not get over-written with DEERS Sync Can navigate from the A/P module by clicking Demographics on Folder List After entering number, press ‘Save’ on top of screen then close.

Making it Legible Free text in Subjective (i. e. Visit For) and Plan (i. e. Comments) p Free text the “Visit for” n n n p Positive Symptoms in HPI (and pertinent negatives) Only negatives in ROS Filled in bullets means abnormal findings; and in PE – abnormal findings list first Free text Comments in A/P

ROS / HPI Flip AIM Form ROS / HPI Flip Button – Also on AIM Forms! p Important not to leave abnormal findings in ROS - toggle to HPI n n If not, difficult to find later When re-reading note, it’s easier to find what significant symptoms were OK to put pertinent normal symptoms in HPI AHLTA 3. 3 will do this automatically Post Flip

Dx Prompt 1 Dx Prompt p Feature is not a template, but will return a list of related symptoms, history, and physical findings to diseases you search 2 3 4

Consults Copy as New p p p Patient shows up needing new consult because previous one expired If you see it below as an Active Consult Right click, select Copy as New, modify No of Visits, then Submit Edit Reason for Request, Change No of visits or Authorization Date, then submit. Right Click, Select ‘Copy as new’

Prompt Button 2 Prompt Button p p Highlight any item on left - brings back related items Ex. Mental Status Exam - highlight depression from Default Template and press prompt, then PE tab 1 3

Procedure Templates Have a Procedure Template in your Favorites Dropdown p p Minor Procedures – Usability AIM Form with a general consent Make your own custom - keep in your default template i. e. Derm/ED, etc. If you do many, repetitively, you might want to include the text blurbs in your default template (Dr. Strode ER Example) or have a specific AIM built Remember corresponding CPT codes in Default Template, or Clinic Favorite List Usability AIM Various Free Text Procedures

Copy Forward p p Use for your follow ups when applicable Auto. Neg becomes Auto. Enter n Be sure to edit any changes to free text narratives or de-select findings not performed this visit – you are still liable for what you leave in the note Previous Encounters Items left in yellow will not print to the note S/O and A/P

Free Text Button p p Fast for documenting Exam findings not bulleted in the template or default you are using at the time. Consider adding bullets to relevant templates later… 1 2 3

My patient Location Room number in Vital Signs Comments

Adding Scanned Docs Adding scanned documents into Add Note p p p Using PDF Creator (free) to print to pdf Opens in Adobe Reader (free) – Snapshot Tool Paste (CTRL V) into Add Note One time setup. Snapshot icon Not on by default, must turn it on In Tools>Customize Toolbars Once placed on tool bar, can Select area to have copied, and Can paste into Add Note (below)

Browse from Here Browse from here p p p Shows where finding is relative to the tree Example - Abdominal Exam on Default Template - Abdomen Soft then press Browse From Here to document other related findings. To go back, click PE tab 2 3 4 1