NextGen Huddle. NEON Provider Meeting April 2011

Transcription

1 NextGen Huddle NEON Provider Meeting April 2011

2 NextGen Huddle Points of Emphasis 1. E&M Coding & Reconciliation: the importance of Code Check and the impact of the HPI template on visit codes 2. Medication Module: the importance of the Stop Date in making sure that Active Medications are reflected in Module and Patient Plan 3. Chronic Problem Reconciliation: the critical importance of assigning Assessments the status of a Chronic Problem 4. Referral Quality: essential elements of task assignment to Referral Coordinators and critical features of a referral letter 5. INBOX Tasks & ToDo tasks: effective use of tasks to keep patients from falling through the cracks.

3 E&M Coding & Reconciliation When the patient is discharged from the health center, the work should be done. E&M coding must be complete. For coding to be complete, the health record must be complete for those elements that affect E&M coding. Nursing staff are obligated to review the record for E&M coding completion; if not complete, they are mandated to inform the provider E&M coding must be complete

4 E&M Coding & Reconciliation: Code Check, CC & HPI For CODE CHECK (or 99201) visit codes are only appropriate for nursing visit codes are the minimally required visit level for medical providers (or series preventive health codes) For Chief Complaints Interact with at least ONE HPI template per visit Use the Generic HPI template if necessary Medication Refill as a Chief Complaint is reserved only for Chart Updates

5 E&M Coding & Reconciliation: You should be able to check off at least 3 important findings about any Chief Complaint (CC). Code Check is driven by HPI more than anything else you document (including PE & ROS elements) Code Check, CC & HPI

6 Medication Module: STOP DATE Long-term medications for Chronic Conditions should be given a Stop Date of at least 12 months at any given time. Upcoming escribing will depend heavily on whether the given medication is ACTIVE. Short-term medications for Acute Problems should be given a Stop Date of as many days or weeks that you feel the diagnosis is still active; beyond a request for a replacement Px for a lost Px would require re-evaluation rather than simply re-writing the Px.

7 Medication Module: MEDS RECONCILIATION Patient Plan must be given to each patient upon discharge as an education and patient safety tool. Current Medication List is a critical and essential element of the Patient Plan. Nursing staff are required to review with patient whether they have a good understanding of their medication profile Prescribing providers must make sure that the Patient Plan reflects all Current Medications. Renew function in Med Module saves times

8 Medication Module: Be careful that you first adjust the Stop Date and then adjust the Quantity. DON T MESS WITH DURATION MEDS RECONCILIATION

9 Chronic Problem Reconciliation Joint Commission requires that our health record reflect the patient s current Chronic Problems. Proper listing of a Current Assessment as a Chronic Problem allows the means for placing the patient in a Computerized Registry. Chart Review by a guest/covering provider is facilitated by a proper listing of Chronic Problems. (Just as having an up-to-date Active Medication Listing) NO CHRONIC PROBLEM SHOULD BE LEFT BEHIND!

10 Chronic Problem Reconciliation

11 Referral Quality: REFERRAL TASK To expedite the Referral Task for referring to outside specialists or for outside procedures the following must be evident to our Referral Coordinators: Clarity on the WHO, WHAT TYPE, WHERE, WHEN Who do you want to serve the patient, if there is a preference What type of specialty service Where does the patient need to be served, if there is a preference When does the patient need to be served, if there is an urgency.

12 Referral Quality: REFERRAL LETTER Referral letters to outside specialists or for outside procedures must have the following features: Clarity on the WHAT TYPE, WHAT, WHY What type of specialist, if applicable, do you want to serve the patient What do you want done Why you want it done Above helps NEON providers appear sophisticated and learned in our use of outside resources. Above helps the outside specialist know what the patient needs instead of asking: Do you know why NEON sent you here?

13 Referral Quality: REFERRAL LETTER Free hand type right into document. Check your spelling. Make the letter look nice.

14 INBOX & ToDo Tasking Like in many games that involve a ball, passing is required before the team can score. Effective utilization of INBOX & ToDo Tasking allows for internal NEON care groups (Providers, QCAT, Referral Coordinator, Central Appointments Nurse Triage) to pass a task prior to completing an important service for our patients. WE MUST PASS BACK TO SCORE; IF WE DON T WE LOSE We lose precious time in serving our patients We lose the respect of our patients We lose the respect of each other We lose in a courtroom of malpractice litigation

15 INBOX & ToDo Tasking Sometimes the Inbox or ToDo task (or pass) is to ourselves and can serve as an important reminder for a critical patient follow-up. INBOX & ToDo tasking creates a Ticker file on-the-fly. INBOX & ToDo tasking is an effective way to keep our patients from falling through the cracks. By keeping our INBOX uncluttered with stuff from our PAQ we have a clearer view of what s in our Inbox. It is important to COMPLETE a task in the INBOX if the task has served its purpose; otherwise, it contributes to INBOX clutter.

16 Inbox & ToDo Tasking : LET S MAKE A DATE

17 Inbox & ToDo Tasking : YES YOU CAN SELF TASKING

18 Inbox & ToDo Tasking : Look Mom, NO HANDS Task SELF TASKING

19 Points that were Emphasized 1. E&M Completing & Reconciliation: the importance of Code Check and the impact of the HPI template on visit codes 2. Medication Module: the importance of the Stop Date in making sure that Active Medications are reflected in Module and Patient Plan and the connection with escribing 3. Chronic Problem Reconciliation: the critical importance of assigning Assessments the status of a Chronic Problem 4. Referral Quality: essential elements of task assignment to Referral Coordinators and critical features of a referral letter 5. INBOX Tasks & ToDo tasks: effective use of tasks to keep patients from falling through the cracks.