Pharmacy Paperless Refill

Presenters:Angela Kihega, RHIT

Oklahoma City Area HIM Consultant

Amy Rubin, PharmDOklahoma City Area Clinical Applications

Coordinator

Learning Objectives• Review the process for Paperless Refill from the

Pharmacist’s perspective.• Compare and contrast .9999 and 999.9 ICD-9 Codes as

they apply to Paperless Refill.• Fix UNCODED ICD9 Diagnoses/Operations for Paperless

Refill• Review and Complete Paperless Refills using the EHR

Coding Queue by Clinic Code• Understand the significance of Pharmacy 12:00 and 13:00

visits• Understand the use and sequencing of the V-Code and

Diagnosis Code

Paperless Refill

• Electronic documentation of pharmacy only or outpatient clinic-initiated refill visits

• Automatically prompts the pharmacist to select POV for each medication refill processed

• Automatically populates necessary EHR fields to complete a pharmacy visit

• Not necessarily paperless

Paperless Refill (Scenario 1)POV with Diagnosis “No errors”

1.Select PAPERLESS REFILL Option

2.Select POV from PROBLEM LIST– Inserts DIAGNOSIS from the PROBLEM

LIST as the SECONDARY POV– V68.1 is the PRIMARY DIAGNOSIS

Paperless Refill (Scenario 1)

Paperless Refill (Scenario 2)POV with an Uncoded Diagnosis of .9999 Code1.Pharmacist Bypasses selecting a Problem List DIAGNOSIS

– Then Pharmacist enters ^ (Shift 6) to FREE TEXT a diagnosis instead

2.Using a FREE TEXT diagnosis results in a .9999 Error Code as a Secondary Diagnosis3.Primary Diagnosis is V68.1

PCC Screen shot of POV: .9999 (Scenario 2)

Paperless Refill (Scenario 3)POV with a 999.9 (Complicated Med Care NEC/NOS)

1.Pharmacist bypasses selecting a diagnosis by using the Shift 6 (^) option

2.System automatically assigns a 999.9 (Complicated Med Care NEC/NOS) code as the SECONDARY diagnosis

3.Primary diagnosis is V68.1

PCC Screen Shot of POV: 999.9 (Scenario 3)

Pharmacy Visits12:00 vs. 13:00

• New prescriptions generate a visit with a time stamp of 12:00

• Prescriptions processed using Paperless refill generate a visit with a time stamp of 13:00

• Pharmacy visits can generate multiple visit entries for the same encounter– Ex: Same Day Visits with 12:00 and 13:00 time Stamp

Same Day Multiple Pharmacy Visits

Pharmacy Visits

When to say NO to paperless refill

New prescription +Refill request = NO

at paperless refill prompt

This results in only one pharmacy visit … only one!

Optional: add POV for refills in EHR

PCC Uncoded POV Report Menu

PCC Patient Care Data Entry Menu ...

DEU Data Entry Utilities ...

SUP Data Entry SUPERVISORY Options and Utilities …

ICD Fix UNCODED ICD9 Diagnoses/Operations ...

POV Fix Uncoded Purpose of Visit Diagnoses

PCC Uncoded POV Report

PCC/EHR Visit Audit

Questions and Discussion