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:
Note: If the visit has been abstracted via interface, the Status will display “Complete Via External Application.”
Note: If the patient is 1 year old or younger, the Height section displays only In and Cm fields.
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.
To update abstracting information, follow these steps:
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:
To delete a diagnosis, follow these steps:
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:
To update a surgical HCPCS code, follow these steps:
To delete a surgical HCPCS code, follow these steps:
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.
To add a note, follow these steps:
The information populates the list.
You can only delete a note prior to saving it. Click the Delete button. The note is removed.
Although notes cannot be deleted once they have been saved, strikethrough lines can be applied to out-of-date notes.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:
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:
To delete a physician, follow these steps:
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:
To delete a procedure, follow these steps:
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:
To delete a surgeon, follow these steps:
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:
To update a charge, follow these steps:
A charge can only be deleted before it is saved. To delete a charge, follow these steps:
Credits can be applied as long as they have the same charge date as the original charge. To add a credit, follow these steps:
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.
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:
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.
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.
To add RUG Score information, follow these steps:
To update a RUG Score, follow these steps:
To delete a RUG Score, follow these steps:
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.