New functionality Abstracting

Ability to enter in soft coding diseases and procedures codes directly to the patient’s encounter

Lorena avatar
Escrito por Lorena
Actualizado hace más de una semana

This option is where your H.I.M staff will work. We offer an integrated coding application very easy to use, in addition to the internal searchable database within eCS as well as the ability to enter in soft coding ICD10 diseases and ICD10-PCS procedures codes directly to the patient’s encounter. In essence, you can charge the medical procedures now to the patient’s encounter, having to give someone else the duty to charge that service.

On the main screen, you can search by Patient Type, Coding Status, Name, Admit Date and Departure date, MRN, Encounter No, Patient’s name or combinations of the search options, or partial combinations. You will also see listed your patients by recent discharge dates.

Once you select your patient you will see the following sections:

Encounter Data: you see the summary of the encounter and the editable fields.

You can correct the patient encounter type, the dates, disposition codes, place of service.

Physicians: You can see the admitting, attending, referring where you can add or delete as necessary

Diagnosis: you can see two tabs:

  1. Encounter diagnosis where you can see all the diagnoses added duraing patient care. You can add if you needed and modify information.

  2. Diagnosis history shows all inactive, unresolved, unconfirmed diagnoses from both this event and past events and cannot be modified.

Coding: You can search for the ICD10 diagnoses, HCPCS/CPT/ACHI Procedures, and ICD10 procedures.

When coding Inpatients, you are able to Obtain the DRG (only if you have a DRG service-connected to ECS Cirrus).

When entering your diagnosis, you have the ability to re-sequence them by simply clicking the diagnosis up or down. You can also assign your POA as appropriate per DX (diagnosis).

Note: To group diagnoses into the proper DRG, you need to identify a Present on Admission (POA) Indicator for all diagnoses reported on claims involving inpatient admissions.

Professional Coding, when the encounter is Outpatient (ambulatory) you are able to enter in the procedure/charges for the physician services. If the charges are already there, you assign the provider that performed that service and assign the DX pertinent to the service.

When you are complete with coding you are able to mark the professional and institutional coding as “Completed”. If you need additional information to complete a section, just save the register and mark it “Completed”, and it will stay as “Draft” …independently from each other.

In case you need more information on Coding & Abstracting, here is the link to the US CMS rules and guidelines for Coding.

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