Diagnosing (Physician)Chapter 15

Add a diagnosis to a patient

Objective

Diagnosing ICD-9 ICD-10 International classification of Diseases World Health Organization(WHO)

Key Concepts

Identifying the condition/symptom that is reason for patient’s visit-key responsibility of physician

Physician must diagnose the patient’s problem into a converted ICD code in order to submit to payer for payment of services

Diagnosing

International Classification of Diseases Have been used in US since 1900 Have been ten revisions of codes since

inception Physicians have been using ICD-9 to report

their diagnoses since 1079 ICD-10 adopted for reporting

mortality(causes of death) on January 1, 1999, but ICD-9 still used for morbidity(health conditions)

ICD Codes

Mandatory adoption date for ICD-10 is October 1, 2014 At this point all physicians will be required to use ICD-

10 for both mortality and morbidity reporting Electronic software companies must also adopt ICD-10

by this deadline ICD codes (both 9 & 10) are provided and maintained

by World Health Organization (WHO) There are more than 14,000 ICD-9 codes but new code

set expands it to over 68,000 ICD-10 codes Increasing the specificity of physician diagnosis coding

ICD-10

Description-entering words to describe diagnosis

ICD code-entering code if known Checklists-based on presenting problems

selected Tree structure-starting at top of diagnosis

tree Problem-based on presenting problem Body part-based on body part(s) affected Top 60 diagnoses

MedTrak enables physician to select diagnosis for patient in many ways

Once physician has examined patient He/she will decide on patient’s diagnosis These diagnoses may/may not coincide with what patient

indicated to front desk person Diagnoses determine what history/exam /aftercare questions

physicians need to use for documenting patient’s visit Alignment of history/exam/aftercare questions are another

part of MedTrak’s problem-focused functionality Diagnosis process facilitates clinical decision support (CDS)

rules which comply with Meaningful Use Core Objective 11 Do This! Pg. 190

Patient Diagnosis

Cursor in Diagnosis field of Visit Documentation screen(Figure 15-1)

Click DX by Checklist button to display Add Diagnosis screen

Note appears at top of screen identifying presenting problem(Figure 15-2)

Add Diagnosis screen functions just like Order Entry screen Plus sign indicates there are more selections available Green cross indicates these are selectable diagnoses Minus sign at top line indicates there are more diagnoses

by going up the diagnosis tree(Figure 15-3)

Selecting A Diagnosis Based On The Presenting Problem

After selecting diagnosis click Exit screen button to return to Visit Documentation screen

ICD-9 code is displayed with description(Figure 15-4) Select diagnosis by using MedTrak Diagnosis Tree MedTrak attaches ICD codes to diagnosis descriptions When diagnosis is selected ICD code is automatically

loaded for documentation and billing purposes There could be multiple diagnoses needed for patient’s

encounter-you can select all of the applicable diagnoses. When required MedTrak will replace ICD-9 with ICD-10

code set

Selecting Diagnosis

Another diagnosis search function: FIND DX by Description Click on Find DX button on Visit

Documentation screen Diagnosis: Find screen appears Enter diagnosis description in Description

field(Figure 15-5)

Selecting A Diagnosis Based On The Description

Click Submit button Add DX by Description screen appears to select Type diagnosis description words in any order Add DX by Description screen refreshed with message “Adding:…….

(your description)” at top of screen If patient has anther diagnosis type the next description in Search

field and click the Search button When done click Exit Screen button to return to Visit Documentation

screen(Figure 15-7) Screen will list selected diagnoses in the Diagnosis section. To delete diagnosis, place cursor next to diagnosis that needs

deleting and click Delete DX button Do This! Pg. 195 & 196

Selecting A Diagnosis Based On The Description