Medical Records Abstracting Tab

The Abstracting tab is used to set a visit’s status for billing and add DRG information. The visit’s abstract status determines whether it will be picked up during a Billing run. The admit and discharge dates and visit information can be updated.

To complete abstracting for a visit, follow these steps:

1. DRG Id – Enter a DRG code in the first field or a DRG description in the autocomplete field (clicking a suggested description to select it). Any previously associated DRG ID displays here. Only one active DRG can be associated with a visit for billing purposes.
2. Status – If a visit has not been abstracted, the default status is Incomplete. Click the dropdown and select from the following:
   • Incomplete – No coding has occurred, and the visit is not ready to be billed. It will not be selected in a billing run.
   • Coded, But Waiting For Review – All codes required for billing have been entered, but the visit must be reviewed before it can be billed. It will not be selected in a billing run.
   • Complete for Billing – All codes required for billing have been entered, and the visit will be selected in a billing run. The Abstract Date displays the current date.
   • Complete for Billing and Reporting – All codes required for billing and reporting have been entered, and the visit will be selected in a billing run. The Abstract Date displays the current date.

Note: If the visit has been abstracted via interface, the Status will display “Complete Via External Application.”

3. Date – Updates when a status is set.
4. Visit No – Displays the selected visit.
5. Location – Displays the visit’s location.
6. Admit Date – Click the field to enter the date directly or click to select a date from a calendar. Then enter the time directly or click the clock icon to select a time.
7. Disch Date – Click the field to enter the date directly or click to select a date from a calendar. Then enter the time directly or click the clock icon to select a time.
8. Patient Type – Click the dropdown and select the patient type for the visit. The type must correspond with the Admit Type and is used to classify patients for room charging, the general ledger, and reporting.
9. Admit Type – Click the dropdown and select the inpatient or outpatient admission type for the visit. If an inpatient type is selected, an inpatient option must be selected in the Patient Type dropdown, and an outpatient option must be selected for an outpatient type.
10. Disposition – Click the dropdown and select the patient’s discharge disposition.
11. Height – Enter the patient’s height into either the Ft (feet) and In (inches) fields or the Cm (centimeters) field. The system converts feet and inches to centimeters and vice versa, and then automatically populates the other field.

    Note: If the patient is 1 year old or younger, the Height section displays only In and Cm fields.

12. Weight – Enter the patient’s weight into either the Lbs (pounds) and Oz (ounces) fields or into the Kg (kilograms) field. The system converts pounds and ounces to kilograms/grams and vice versa, and then automatically populates the other field.

    Note: RCM Cloud^® has a height/weight check option that checks for the reasonability of the height and weight entered compared to the patient’s age. If the height/weight entered vary from chart averages, a warning message displays when Save is clicked, helping reduce the chance of errors when entering the information.

13. Click Save.

Update Abstracting Information

To update abstracting information, follow these steps:

1. Select the visit from a search or work queue.
2. Make any necessary changes.
3. Click Save.

Diagnosis

The Diagnosis tab is used to add or delete diagnoses (admitting, final, or secondary) for the visit. The diagnoses indicate what a patient is being treated for and can work in conjunction with Medical Necessity Checking to verify the necessity of certain procedures.

While multiple diagnoses can be added, only one admitting and one final diagnosis are allowed on the visit. Secondary diagnoses have no limit.

Diagnoses can be added to the visit record by using existing diagnosis codes or by entering free-form text. Only admitting and secondary diagnoses can be added via free-form text.

To add a diagnosis, follow these steps:

1. Click the Add  button. A row is added to the list, and the Type dropdown menu defaults to:
   • Admitting – If there are no other diagnosis codes associated with the visit. This is the diagnosis/major complaint when the patient was admitted.
   • Final – If there is an admitting diagnosis code associated with the visit. This is the official diagnosis (if determined to be different from the admitting diagnosis), as determined by the facility’s personnel, and the issue treated.
   • Secondary – If there are admitting and final diagnoses codes associated with the visit. This is a diagnosis that is recorded for tracking but may not be related to the principal diagnosis.

2. Type – Click the drop-down and select a diagnosis type, if needed.
3. POA – Click the drop-down and select an option to identify if the diagnosis was present on admission.
4. Enter the diagnosis by one of the following methods:
   • Diagnosis – Enter a diagnosis code in the first field or a diagnosis description in the autocomplete field (clicking a suggested description to select it).

• • Freeform – Enter free-form text into the field.

5. Click Save.

Delete Diagnoses

To delete a diagnosis, follow these steps:

1. Click on a diagnosis in the list to select it.
2. Click the Delete button . The diagnosis is deleted from the list.
3. Click Save.

Surgical HCPCS

The Surgical Hcpcs tab is used to add or delete HCPCS codes related to surgical procedures. The date, revenue ID, and HCPCS code and modifiers can be saved for the surgical procedure.

To add a surgical HCPCS code, follow these steps:

1. Click the Add  button. A row is added to the list, and the Surgical Hcpcs Information fields below are enabled.

2. Date – Click the field to enter the date directly or click to select a date from a calendar.
3. Rev Id – Enter a revenue ID in the first field or a revenue ID description in the autocomplete field (clicking a suggested description to select it).
4. HCPCS – Enter a HCPCS code in the first field or a HCPCS description in the autocomplete field (clicking a suggested description to select it).
5. Modifiers – Enter any HCPCS modifier codes. The first field is enabled when an HCPCS code is entered above. The second field is enabled after an entry in the first field.

6. Click Save.

Update Surgical HCPCS Codes

To update a surgical HCPCS code, follow these steps:

1. Click on a code in the list to select it.
2. Update the date, revenue ID, HCPCS code, or modifiers.
3. Click Save.

Delete Surgical HCPCS Codes

To delete a surgical HCPCS code, follow these steps:

1. Click on a code in the list to select it.
2. Click the Delete button . The code is deleted from the list.
3. Click Save.

Notes

The Notes tab lists all user and system-generated notes that are associated with the visit. Note information includes the date, user, code, and narrative. Notes can be sorted by clicking on the column headers. Coded or free-form notes can be added in the tab.

Click the System Notes checkbox to view only system-generated notes.

Add Notes

To add a note, follow these steps:

1. Click the Add button . A row is added to the Notes list with the current date, user adding the note, and the application area (Collections, Billing, Registration, etc.) populated and the Visit Note Information fields enabled.

2. Enter note information using one the following options:
   • Coded note – Enter a note code in the first field or a note description in the autocomplete field (clicking a suggested description to select it).

• • Free-form note – Enter free-form note text into the Narrative field.

The information populates the list.

You can only delete a note prior to saving it. Click the Delete  button. The note is removed.

3. Click Save.

Strikethrough a Note

Although notes cannot be deleted once they have been saved, strikethrough lines can be applied to out-of-date notes. The Strike action is located to the right of the Narrative field for saved notes. The strikethrough option allows notes to be designated as no longer used, helping the user determine which information is current on the medical record. Strikethrough lines can be removed. To strike a note, follow these steps:

1. Click Strike in the Action column to the right of the note narrative. A strikethrough line displays over the note’s fields.

2. Click Save.
3. To remove the strikethrough line, click Un-Strike.

Physicians

The Physician tab is used to add or delete physicians (admitting, attending, etc.) to the visit. This provides a history of physicians who have treated the patient during the visit. While multiple physicians can be added, only one Admitting and one Attending physician are allowed on the visit.

To add a physician, follow these steps:

1. Click the Add  button. A row is added to the list, and the Physician Information fields below are enabled.

2. Type – Click the dropdown menu and select a Physician Type (attending, consulting, ordering, etc.).
3. Phys Id – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).

4. Click Save.

Delete Physicians

To delete a physician, follow these steps:

1. Click on a physician in the list to select it.
2. Click the Delete button . The physician is deleted from the list.
3. Click Save.

Procedure

The Procedure tab is used to add or delete procedure codes for a visit. Procedures can be added as principal or secondary, but a visit can only have one principal procedure. Procedures cannot be updated. In Medical Records, surgeons can also be added for the procedure.

To add a procedure, follow these steps:

1. Click the Add  button. A row is added to the list, and the Procedure Information fields below are enabled. The Type drop-down menu will default to Principal if there are no procedures on the visit and Secondary if there is already a Principal type.

2. Type – Click the dropdown and select a procedure type (principal or secondary).
3. Procedure – Enter a procedure code in the first field or a procedure description in the autocomplete field (clicking a suggested description to select it).
4. Date – This date defaults to the admit date. Click the field to enter the date directly or click to select a date from a calendar.

5. Click Save.

Delete Procedures

To delete a procedure, follow these steps:

1. Click on a procedure in the list to select it.
2. Click the Delete button . The procedure is deleted from the list.
3. Click Save.

Surgeons

The Surgeons window allows surgeons to be associated with a procedure. The procedure must be added in the Procedures tab first.

To add a surgeon, follow these steps:

1. Click the Surgeons button. The Surgeons window displays.

2. Click the Add button . A row is added to the list and the Physician fields are enabled.

3. Physician – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).

4. Primary – Check to designate the physician as the primary surgeon. If multiple surgeons are added, the primary surgeon will be listed first.

5. Click Save.

Delete Surgeons

To delete a surgeon, follow these steps:

1. Click on a surgeon in the list to select it.
2. Click the Delete button . The surgeon is deleted.
3. Click Save.

HCPCS Related Charges

The HCPCS Related Charges tab is used to manage CPT codes (HCPCS codes) and their corresponding charges on an account. The tab displays any previously associated CPT codes (charges without CPT codes may not be displayed). CPT codes and their associated charges can be added, along with HCPCS Modifiers, physicians, and diagnoses. If a HCPCS code is associated with multiple charges, a window displays and allows the user to select the specific charge.

To add a charge, follow these steps:

1. Click the Add button . A row is added to the list, and the entry fields are enabled, with the current date populating the Date field.

2. Hcpcs – Enter a HCPCS code in the first field or a HCPCS description in the autocomplete field (clicking a suggested description to select it). If more than one charge is associated with the HCPCS code, the HCPCS Associated Charges window displays and lists all charge codes associated with the selected HCPCS code.

3. Click on a charge code in the list to select it.
4. Click Save. The charge code is selected. In the list, click + to expand the code and view the charge associated with the HCPCS code.

5. Mod – Enter any HCPCS modifier codes. The first modifier field is enabled when an HCPCS code is entered. The second field is enabled when a modifier is entered in the first field, and so on. The modifier codes clarify the services billed while not changing the procedure code. They add more information, such as the anatomical site, to the HCPCS code. In addition, they help to eliminate the appearance of duplicate billing and unbundling.
6. Physician – Enter a physician code in the first field or a physician name in the autocomplete field (clicking a suggested description to select it).
7. Diagnosis – Click the Diagnosis button to rank diagnoses already associated with the visit.
8. Date – Click the field to enter the date directly or click to select a date from a calendar. Then enter the time directly or click the clock icon to select a time. This will be the charge date.
9. Quantity – Enter the quantity of charges.

10. Click Save.

Update Charges

To update a charge, follow these steps:

1. Click on a HCPCS code in the list to select it.
2. Make any necessary changes to the charge, HCPCS modifiers, date, quantity, Physician, or Diagnosis.
3. Click Save.

Delete Charges

A charge can only be deleted before it is saved. To delete a charge, follow these steps:

1. Click on a HCPCS code in the list to select it.
2. Click the Delete button . The code is deleted.
3. Click Save.

Credit Charges

Credits can be applied as long as they have the same charge date as the original charge. To add a credit, follow these steps:

1. Click on a HCPCS code in the list to select it.
2. Click the Credit button . The credit row is added to the list with the quantity displayed as a negative number, and the fields are enabled below the list.

3. Click Save. The credit will be listed with negative numbers and no Credit button .

Charge Diagnosis

The Charge Diagnosis option is used to associate a diagnosis or multiple diagnoses with a charge and rank them. The user can assign up to four diagnoses that have already been associated with the visit. Those diagnoses can be ranked, which determines their order on the 1500 and 837p.

Note: The 1500 billing option for the diagnosis pointer field (FL24E) must be set to 8.

Associate Diagnoses

The Charge Diagnosis window displays all associated diagnoses. Up to four diagnoses can be ranked, but they cannot have the same rank. To associate and rank diagnoses, follow these steps:

1. Click on the arrows or enter the rank directly into the Rank field for a diagnosis.

2. Click Save. The Rank 1 diagnosis displays in the Diagnosis field on the Charges tab.

Room/Bed

The Room/Bed tab displays information regarding admissions, transfers, discharges, etc. for a visit. The read-only tab lists the effective date along with the description and create date for the activity.

RUG Score

The RUG Score tab allows users to add Resource Utilization Group (RUG) scores to an account. RUG Scores are used to classify beneficiary groups based on care and resource needs for skilled nursing facilities.

Each RUG classification (rehabilitation services, special care, clinically complex, etc.) signifies a different Medicare per diem payment term. RUG Score information, in conjunction with billing settings, is included in the 837i electronic billing file.

Add RUG Score Information

To add RUG Score information, follow these steps:

1. Click the Add button . A row is added to the list.

2. RUG Score – Enter the RUG calculation code.
3. Date – Click the field to enter the date directly or click to select a date from a calendar..
4. Quantity – Enter the quantity.
5. Rev Id – Enter a revenue ID in the first field or a revenue ID description in the autocomplete field (clicking a suggested description to select it).

6. Click Save.

Update RUG Score

To update a RUG Score, follow these steps:

1. Click on a score in the list to select it.
2. Make any necessary changes.
3. Click Save.

Delete RUG Score

DRG History

The DRG History tab displays historical DRG codes that have been associated with the visit. The tab displays the code and the date it was added.