Patient Care Component PCC Data Entry Coding

Patient Care Component (PCC) Data Entry & Coding Pat Gowan, MPA, RHIA National Medical Records Consultant Phoenix Area Office

PCC DE & Coding • • PCC Overview PCC Forms PCC Data Entry Health Summary Coding PCC Manuals PCC Training Classes

PCC Overview • PCC provides for the collection, integration, and storage of a broad range of health data resulting from outpatient, inpatient, and field visits. • It is designed to support health care delivery, planning, management, and research. • It is a tool that assists in providing the type of care that addresses all of a patient's known health problems and preventive health needs. • It includes date, type, and location of visit; providers; measurements; diagnoses and procedures; health problems and treatment plans; personal and family history; reproductive factors; lab test results; and a variety of other health-related information.

PCC Forms • • • Ambulatory Encounter Record, IHS-803 Emergency Visit Record, IHS-114 Brief Visit Record, IHS-464 Multi-Visit Encounter Record, IHS-372 Group Preventive Services, IHS-367 Adult History and Physical Examination Record, IHS-465

Preparing Forms for Data Entry • All forms must be screened for the following items prior to being entered: – Date, Time, Location (e. g. , school) – Clinic – Primary provider – Purpose of Visit/diagnosis – Patient ID (name, health record number) – Signature of the primary care provider.

PCC Data Entry • The Data Entry Module facilitates entry of information about a patient from a variety of forms into the PCC. • The most commonly used form is the PCC Ambulatory Encounter Record, IHS-803. • A patient must be registered in Patient Registration before any data can be entered.

Data Entry • The following data items will be entered if recorded on the form: – Secondary Provider (s) – Measurements: Height, Weight, Blood Pressure, Head Circumference, and Vision – Lab Tests Ordered (only if Laboratory Module is not operational) – Procedures – Exams Performed – Immunizations – Skin Test Readings/Results – Problems and/or Notes – Cause and Place of Injury on First Visits – Reproductive Factors – Personal or Family History – History of Immunization, Skin Test Readings, and Procedures

PCC Menu • The data entry system consists of the following features: – On-line help screens – On-line help prompts – On-line entry to multiple PCC dictionaries (e. g. , Visit, Provider, Purpose of Visit, Measurement, etc. ) – On-line editing and visual verification of data entered – Computer-assisted (encoder) ICD-9 diagnostic and ICD-9 and CPT procedural coding.

DATA ENTRY MNEMONICS • MNEMONICS are used to facilitate entry of patient data into the PCC system. • A mnemonic consists of two to three characters, e. g. , BP, WT that represent a specific data type and speed entry by reducing the number of key strokes necessary to enter patient health information. • A complete list of the mnemonics can be viewed by typing a

MNEMONICS

Health Summary ***************** ** PCC Data Entry Module ** ***************** Version 2. 0 DEMO WALK-IN CENTER ENT DSP PEF UPD DEU GHS BHS DVB PDV Enter/Modify/Append PCC Data. . . Display Data for a Specific Patient Visit Print a PCC Visit in Encounter Form format Update Patient Related/Non Visit Data. . . Data Entry Utilities. . . Generate Health Summary Browse Health Summary Display a PCC Visit w/limited Lab Display Print a PCC Visit Display to a Printer

GHS Option • The GENERATE HEALTH SUMMARY (GHS) menu option is used to display a health summary for a specific patient on screen (View) or print. • The default health summary is the ADULT REGULAR. • Other standardized health summaries are: Pediatric, Dental, Immunization and Diabetes. • Health summaries may be customized.

Health Summary Display

Health Summary Display

COD Option LST GHS AUN MRG DEL SUP BHS COD GC MR 2 List Visits for a Patient in a Date Range Generate Health Summary Find CHS Entry for a Given Authorization Number Merge two Visits on Same Date Delete All Data For A Visit Data Entry SUPERVISORY Options and Utilities. . . Browse Health Summary Display IHS Coding Guidelines Pediatric Growth Charts Merge 2 Visits on 2 Different Dates

Coding Guidelines • OCD Option DISPLAY IHS CODING GUIDELINES allows the user to view the ICD-9 Coding Guidelines. • Official Coding Guidelines are also located in front of the ICD-9 -CM Code book.

Official Coding Guidelines

. 9999 CODE • If the provider or the coder is unable to locate the appropriate code in the ICD-9 file or in the book, the code. 9999 (UNCODED DIAGNOSIS) may be entered at the PURPOSE of VISIT prompt. • . 9999 codes must be modified to an ICD-9 code

E-Codes (E 800 -E 999) • External causes of Injury, Poisoning, and other Adverse Effects • E-codes should be used in addition to a code from the main chapters of the ICD-9 book indicating the nature of the condition

E-Code and Place of Occurrence Codes (E 849) • MNEMONIC: PV • • Enter PURPOSE of VISIT: 825. 20. . . OK? Yes// (Yes) Purpose of Visit ALLOWED VISIT RELATED ONLY FX FOOT BONE NOS-CLOSED • • PROVIDER NARRATIVE: FRACTURE RIGHT FOOT MODIFIER: CAUSE (E-CODE): E 880. 1 FALL ON OR FROM SIDEWALK CURB. . . OK? Yes// (Yes) • • CAUSE (ECODE) #2: CAUSE (ECODE) #3: PLACE OF OCCURRENCE (E 849. 0 -E 849. 9): E 849. 0. . . OK? Yes// (Yes) • DATE OF INJURY: T-7 (JUN 06, 2008) ACCIDENT IN HOME

V Codes (V 01 -V 86) • Supplementary classification of factors influencing health status and contact with health services – Person who is not currently sick visits the facility for immunizations – Person seeks treatment such as for dialysis, chemotherapy, cast change – Personal history of certain diseases, e. g. , cancer – Telephone calls, Chart Reviews, Pharmacy refill plus the code for the reason/diagnosis

PCC Coding Queue • The Coding Queue captures all electronically created visits into a holding queue. • Prevents visits not reviewed by data entry/coder from passing directly to the RPMS TP Billing package or from exporting.

PCC Master Control

Reviewed/Complete Visit

Incomplete Visit

Provider and Clinic Codes http: //www. ihs. gov/CIO/scb/index. cfm? module=W_CLINIC&option=list&num=82&newquery=1

PCC Manuals • Patient Care Component (PCC) Operator’s (User) Manual • Patient Care Component (PCC) Supervisor’s Manual • Patient Care Component (PCC) Mnemonics

PCC Manuals http: //www. ihs. gov/Cio/RPMS/index. cfm? module=home&option=documents

Training Classes • PCC Data Entry I User Training • PCC Data Entry II Supervisor Training • PCC Outputs Reporting

Training Classes

Questions?