Hospital Coding Info Form

The Hospital Coding Info form serves as a data repository for a patient's coding information. On this form, you can view coding information and perform coding tasks. Access to the Hospital Coding Info form from the Hospital Billing menu in Hyperspace by selected using the following actions: Hospital Billing > Account Maintenance and navigating to the Coding Info activity tab. At any point, you can switch to a floating mode by clicking a button just below the toolbar, or switch back to normal mode by clicking the same button. While in floating mode, the coding activity appears in a separate window. You can perform other activities in Hyperspace while keeping your coding form open for editing, which can make it easier to check other areas of Hyperspace for information you might need for coding.To view coding information on the Hospital Coding Info form, you must have security point 109-MAY View Coding Information. To use the buttons on the Hospital Coding Info form, you must have security point 43-MAY Code Account in your security classification.To have edit access to all of the fields on the Hospital Coding Info form, you must have security point 110-MAY Edit Coding Information in your Hospital Billing security classification. You can opt to have edit access to specific types of coding information on the Hospital Coding Info form by having one or more of the following security points in your security classification instead of security point 110. In this case, you must not have security point 110 in your security classification: 300-MAY Edit Diagnosis Codes. Allows edit access to the Diagnoses tab of the Coding

activity. 301-MAY Edit Procedure Codes. Allows edit access to the Procedures tab of the Coding

activity. 303-MAY Edit Grouper Codes. Allows edit access to the Groupers tab of the Coding activity. 304-MAY Edit Visit Info. Allows edit access to the ADT Info tab of the Coding activity.

To edit any of these tabs regardless of the coding status of the account even when you are not the assigned coder, you must have security point 299-MAY Edit Cod/Abs When Not Assigned User in your security classification.

ADT Info Tab

On the ADT Info tab, you enter and view admission, discharge, provider, and patient information. This tab is accessible from both the Hospital Coding Info and Medical Records Abstracting forms. Any changes made on it in one of these forms are automatically reflected on the other form. This tab is not editable if coding is completed on the account or if you are not currently the coder assigned to it. In these cases, the tab is editable only if you have security point 299-MAY

Edit Cod/Abs When Not Assigned User. If you do not have security point 299, you must have security point 43-MAY Code Account to assign yourself as the coder and enable the form for editing. In addition, you must have either security point 110-MAY Edit Coding Information or security point 304-MAY Edit Visit Info to edit information on the ADT Info tab.

Hospital Coding Info form - ADT Info tab

Admission Information

Admission dateThe patient's admission date. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.TimeThe patient's admission time. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.Inpatient admission dateThe date that the patient was admitted with a status of Inpatient. This can be different from the admission date if the patient is admitted, then later is transferred to Inpatient status. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.

This field cannot be manually edited because it must be consistent with items in other master files to prevent errors.Inpatient admission timeThe time that the patient was admitted with a status of Inpatient. This can be different from the admission time if the patient is admitted, then later is transferred to Inpatient status. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.This field cannot be manually edited because it must be consistent with items in other master files to prevent errors.Admission typeThe patient's admission type. Select an admission type from the category list. This field's category list displays both patient and claim values, that is, the values in items Hospital Admission Type (I EPT 18875) and Admission Type (Priority) (I HAR 7040), respectively. The two distinct lists are mapped according to the configuration you have set up between these items' values on the Hospital Account Pull Info Category Mappings screen in your Hospital Billing system definition profile settings. Admission sourceThe type of facility or organization from which the patient was admitted. Select an admission source from the category list. This field's category list displays both the patient and claim values, that is, the values in items Admission Source (I EPT 10310) and Admission Source (I HAR 7041), respectively. The two distinct lists are mapped according to the configuration you have set up between the two items' values on the Hospital Account Pull Info Category Mappings screen in your Hospital Billing system definition profile settings.Admission categoryThe admission category for the corresponding patient contact. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record. Means of arrivalThe patient's means of arrival to the hospital. This information is copied into this field automatically from ADT after the Pull Info action is executed on the account or the minimum days for billing have been met. Primary serviceThe primary service performed. Select a service from the category list. This information is copied into this field automatically from ADT after the Pull Info action is executed on the account or the minimum days for billing have been met. Secondary serviceThe secondary service performed. Select a service from the category list.Transfer sourceThe patient's transfer source. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.

Discharge Information

Discharge dateThe patient's discharge date. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.TimeThe patient's discharge time. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record. Discharge dispositionThe patient's discharge disposition. Select a discharge disposition from the category list. Note: If you have shared security point 96-Cannot change patient status to deceased in your shared security classification, you are not be able to select Expired in this field.This field's category list displays both the patient and claim values, that is, the values in items Discharge Disposition (I EPT 18888) and Patient Status (I HAR 7055), respectively. The two distinct lists are mapped according to the configuration you have set up between the two items' values on the Hospital Account Pull Info Category Mappings screen in your Hospital Billing system definition profile settings. Discharge destinationThe patient's discharge destination. Select a discharge destination from the category list. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record.

Provider Information

Admitting providerThe patient's admitting provider. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record. Attending providerThe patient's attending provider. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record. Referring providerThe patient's referring provider. When the Pull Info action is executed on the account or the account's minimum days for billing have been met, this information is copied from the patient record. Other provider(s)The patient's other provider or providers. Enter one or more providers in the Provider column and, for each provider, indicate the role in the Role column.

Patient Information

Displays patient demographic information. You can configure what patient information appears in this section based on your organization's needs on the Coding and Abstracting Configuration form (Admin > HB Admin > System Profile Maintenance). See the Coding and Abstracting Configuration Form section of this guide for more details.

Diagnoses Tab

On the Diagnoses tab, you enter coding information regarding the admission, final, and external injury (E-code) diagnoses on the account via an interface from your third-party coding system or manually. You can define the specific diagnosis code types that can be entered in these tables. You enter the selected types in the Allowed Diagnosis Types field on the Diagnosis Options screen in your facility-level service area profile (Hospital Billing Main menu > Administrator Menu > Service Area Profile > Service Area Settings). When you specify a diagnosis type on this screen, the entry of diagnoses on the Diagnoses tab is restricted to the types listed in the text settings. If no diagnosis types are listed on this screen, then any diagnosis of any type may be entered on the Hospital Coding Info form. This tab is not editable if coding is completed on the account or if you are not currently the coder assigned to it. In addition, you must have either security point 110-MAY Edit Coding Information or security point 300-MAY Edit Diagnosis Codes to edit information on the Diagnoses tab.

Hospital Coding Info form - Diagnoses tab

Admission Diagnoses/Reason for Visit Diagnoses Table

In hospital accounts with a base class of Inpatient, this table is titled Admission diagnoses and stores admission diagnosis codes.In hospital accounts with a base class of Outpatient or Emergency, this table is titled Reason for visit diagnoses and stores Reason For Visit (RFV) diagnosis codes.CodeThe patient's admission or Reason for Visit diagnosis code. Choose from a list of diagnoses. For inpatient accounts, the first code in this table appears in form locator 76 of the UB claim form.NameThe name of the patient's admission or Reason for Visit diagnosis. This value automatically populates from the Diagnosis (EDG) master file when you enter the code.

CommentsComments associated with the admission or Reason for Visit diagnosis for the hospital account. Enter free-text.

Final Diagnoses Table

CodeThe patient's final diagnosis code. Choose from a list of diagnoses. The first code in this table is considered the primary diagnosis and appears in form locator 67 of the UB claim form. If entered on the Final Diagnoses table, as many as eight additional codes appear in form locators 68-75 of the UB claim form.NameThe name of the patient's final diagnosis. This value automatically populates from the Diagnosis (EDG) master file when you enter the code.XcldIndicates whether or not the diagnosis code should be excluded from clinical reporting when it is copied from the source to the target account during account combination.POAThe Present on Admission flag indicates whether the diagnosis was present on admission. Select Yes, No, Unknown, Clinically Undetermined, or Exempt from POA Reporting.CCThe Complications and Comorbidity flag indicates whether complications and comorbidity that may affect the diagnosis exist. Enter one of the following: MCC if there is a Major Complication/Comorbidity CC if there is a non-major Complication/Comorbidity No if there is no complication or comorbidity

HACIf yes, the associated diagnosis contributed to the identification of a Hospital Acquired Condition (HAC).Affects DRGThe Affects DRG flag indicates whether the diagnosis affects the diagnosis related group. Enter Yes or No.

E-Codes Table

CodeThe diagnosis code for any external injury (E-code) related to this hospital account. Choose from a list of diagnoses. The first code in this table appears in form locator 77 of the UB claim form.NameThe name of the patient's external injury diagnosis. This value automatically populates from the Diagnosis (EDG) master file when you enter the code.XcldIndicates whether or not the diagnosis code should be excluded from clinical reporting when it is copied from the source to the target account during account combination.

POAThe Present on Admission flag indicates whether the diagnosis was present on admission. Enter Yes, No, or Unknown.CCThe Complications and Comorbidity flag indicates whether complications and comorbidity that may affect the diagnosis exist. Enter one of the following: MCC if there is a Major Complication/Comorbidity CC if there is a non-major Complication/Comorbidity No if there is no complication or comorbidity

HACIf yes, the associated diagnosis contributed to the identification of a Hospital Acquired Condition (HAC).Affects DRGThe Affects DRG flag indicates whether the diagnosis affects the diagnosis related group. Enter Yes or No.

Procedures Tab

On the Procedures tab, you enter coding information regarding inpatient procedures, CPT/HCPCS codes, and procedure events via an interface from your third-party coding system or manually. This tab is not editable if coding is completed on the account or if you are not currently the coder assigned to it. In addition, you must have either security point 110-MAY Edit Coding Information or security point 301-MAY Edit Procedure Codes to edit information on the Procedures tab.

Hospital Coding Info form - Procedures tab

Procedures Tab Buttons

Date & Provider EntryAllows you to quickly enter the providers and dates for all coded procedures on this tab. Click it to access the Quick Date & Provider Entry window where you specify the default service date and physician for the procedures on this account.Hide Additional ProvidersHides or shows the Additional Providers tables.Hide Extra ColumnsHides or shows several columns on the CPT/HCPCS codes table, such as APC Code and Exp Reimb, that you might not find useful.

ICD Procedures Table

CodeThe inpatient procedure code. Enter a code.You can look up inpatient procedure codes by entering the four numeric characters of the external ID with or without a decimal point (NN.NN or NNNN, where "N" is a numeric character).

Note: If there are inpatient procedure records whose external IDs are NN.NN and NNNN, with identical numeric characters, then looking up the procedure in the NNNN format always retrieves the latter code. If there isn't such a procedure record, then the look-up function retrieves the NN.NN code.NameThe name of the inpatient procedure. This value automatically populates from the ICD Procedure (HCD) master file when you enter the code.DateThe date each inpatient procedure was performed. Enter a date. If you link an event from the Procedure events table to your ICD procedure code, the appropriate date automatically appears here.Performing ProviderThe provider that performed the inpatient procedure. Enter a provider. If you link an event from the Procedure events table to your ICD procedure code, the appropriate provider automatically appears here.Event NumberThe event in the Procedure events table to which this procedure applies. Enter an event number. XcldIndicates whether or not the procedure code should be excluded from clinical reporting when it is copied from the source to the target account during account combination.

ICD Procedures - Additional Providers Table

ProviderEnter any additional providers associated with the selected ICD procedure.RoleEnter the provider's role.CommentEnter a comment about the provider.

CPT®/HCPCS Codes Table

CPT © 2008 American Medical Association. All Rights Reserved.

CPT® CodesThe CPT code for a procedure performed on the patient. Enter a CPT code. Modifier(s)Modifiers for the CPT code. Enter a modifier.CPT® DateThe date the CPT code procedure was performed. Enter a date. If you link an event from the Procedure events table to your CPT code procedure, the appropriate date automatically appears here.Performing ProviderThe provider that performed the procedure. Enter a provider. If you link an event from the Procedure events table to your CPT code procedure, the appropriate provider automatically appears here.EventThe event in the procedure event table to which the CPT code applies. Enter an event number. XcldIndicates whether or not the procedure code should be excluded from clinical reporting when it is copied from the source to the target account during account combination.LCD CodeThe Local Coverage Determination (LCD) code associated with the CPT code. The LCD code is the code used when verifying procedures against LCD edits. For procedures set up without an LCD code, the CPT code is used. If your facility has Health works data loaded, you can press F5 while in this field to view a list of the dashed codes and descriptions, if any apply to this procedure.Rev CodeThe revenue code associated with this CPT code.APC CodeThe Ambulatory Payment Classification code associated with the CPT code. Enter a code.Sts IndThe APC payment status indicator. Enter an indicator.Pmt IndThe APC payment indicator. Enter an indicator.APC WtThe APC payment weight for the procedure. Enter a weight.Unadj PmtThe payment amount to be made for the APC. Enter an amount.Exp ReimbThe expected APC reimbursement for the procedure. Enter an amount.Copay AmtThe copay amount associated with the procedure.Pmt Mthd

The payment method used for the procedure. Enter a payment method.OCE EditThe Outpatient Code Editor code. Enter a code.Disc FactorThe discount factor associated with the procedure. Enter an amount.Affects DRGIndicates whether the procedure affects the diagnosis related group. Enter Yes or No.

CPT/HCPCS Codes - Additional Providers Table

ProviderEnter any other providers associated with the selected CPT code.RoleEnter the provider's role.CommentEnter a comment about the provider.

Procedure Events Table

ProvidersThe provider for each procedure event. Select a provider from the list.DateThe date associated with each procedure event. Enter a date.CommentThe comment associated with each procedure event. Enter free-text. ASA ClassThe ASA (American Society of Anesthesiologists) class for the procedure event. Enter an ASA class.Anesthesia TypeThe anesthesia type used in the procedure, if any. Select an anesthesia type from the category list. Anesthesiologist/CRNAThe anesthesiologist or certified registered nurse anesthetist for the event. Select a provider from the list.

Groupers Tab

On the Groupers tab, you enter information regarding Diagnosis Related Groups (DRGs) via an interface from your third-party coding system or manually. The tab contains two sections: Multiple DRG Information table and Billing DRG Information section. Note that the table and the Billing DRG Type field appear only if you have enabled your DRG master file for Identity. If your DRG master file is Identity-enabled, any DRG types specified for the hospital account appear with their Identity ID.If you use a single DRG Type, the field is labeled DRG Type and the table is hidden because it is not relevant. If you use multiple DRG Types, the field is labeled Billing DRG Type and the table appears. For each applicable DRG system for the hospital account, the Multiple DRGs Information table displays the different Identity IDs for the DRG assigned to the account. If that table is not present, the data related to the DRG is displayed in separate fields.This tab is not editable if coding is completed on the account or if you are not currently the coder assigned to it. In addition, you must have security point 110-MAY Edit Coding Information or security point 303-MAY Edit Grouper Codes to edit information on the Groupers tab.

Hospital Coding Info form - Groupers tab[Enlarge]

DRG Information FieldsThese fields display DRG information. Using Identity ID types, your system may be set up so that a DRG has multiple Identity IDs. Within the context of DRG codes, an ID type may either be synonymous with a DRG code set (e.g., APR-DRG) or version (e.g., CMS DRG V 20.0). For a given system profile or payor, you can then specify the DRG ID types in use and the corresponding effective dates. Therefore, based on a hospital account's payors and service area, an account may contain multiple DRGs, one for each applicable DRG ID type. For instance, a hospital may have to use one DRG code set to bill a payor and another DRG code set for reporting to a particular agency. DRG TypeThe billing DRG ID type. QualifierAn additional categorizer for the associated DLG type and code.DRG

The DRG code for the corresponding DRG type. DescriptionA description of the DRG. BillingThis box is checked for the DRG that is the Billing DRG.Exp reimbThe DRG expected reimbursement, as calculated by a third-party coding system. MDC valueThe DRG's major diagnostic category. WeightNormalized prediction of resource consumption. PSPatient severity. ROMRisk of mortality. short LOSShort length of stay. Long LOSLong length of stay. AMLOSArithmetic mean length of stay. GMLOSGeometric mean length of stay. Cost OL ThrshThe DRG cost outlier threshold.Day OL ThrshThe DRG day outlier threshold.OL AmtThe DRG outlier reimbursement amount.OL TypeThe DRG outlier type.OL DaysThe number of DRG outlier days.OL CostThe DRG outlier cost.OL ReimbThe DRG outlier reimbursement.

Reimb IndThe DRG patient status.DSH AmtThe DRG disproportionate share amount.IME AmtThe DRG indirect medical education amount.Cap AmtThe DRG capital amount.Tot ChgsThe total amount of DRG charges on the claim.LOSThe billing DRG length of stay.Inlier AmtThe normal patient reimbursement for the DRG.Natl RateThe DRG target federal blended rate.Cond CodeThe DRG conditional code.DRG FormulaThe DRG formula.DRG CommentThe DRG comment.

Case-Mix Group FieldsCMG CodeCMGs (Case-Mix Groups) are the Prospective Payment System for Rehab patients. This field accepts an alphanumeric sequence between A0000 and D9999.CMG DateThe date that the inpatient rehabilitation Patient Assessment Instrument (PAI) record was transmitted to CMS.

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Coding Query TabCoders can send messages to physicians via In Basket to further clarify information necessary in the coding process. Here, you can create new coding clarification messages and see the messages previously sent for this hospital account. Physicians receive the message in the Coding Clarification Request folder in their In Basket. This form is read-only in the following circumstances: Your third-party encoder has been launched to code this hospital account. The status of the hospital account is closed, voided, or archived.

You do not have security point 43-MAY Code Account in your security classification. The account is not at the place of service for an IntraConnect deployment.

Hospital Coding Info form - Coding Query tab[Enlarge]

Coding Query TableThe Coding Clarification Requests table lists the coding clarification requests created for this hospital account. By default, the system displays the messages sorted in reverse chronological order. You can click any column heading to sort by that item. You can resize the table columns by hovering the mouse over the column header dividers. When the cursor changes, click and drag the column divider to the right or left.When you select a request in the table, the text of the message appears in the message pane below the table. You can resize the height of the display pane by hovering the mouse over the gray horizontal divider between the table and the message pane. When the cursor changes, click and drag the divider up or down.To include deleted messages on the table, select the Include deleted queries checkbox.SenderDisplays the coder who sent the coding clarification request.PhysicianDisplays the provider to whom the coding clarification request was sent.

SubjectDisplays the subject of the coding clarification request. The body of the message appears in the read-only pane below the table. Create DateDisplays the date and time the coding clarification request was sent. Update DateDisplays the date and time the coding clarification request was last updated.StatusDisplays the current status of the coding clarification request: Request Sent Response Received Completed

Note: The Response Received status is enabled as a property for use in routing and workqueue rules in account workqueues. Therefore, you can create account workqueues that collect the hospital accounts with coding clarification requests that have a status of Response Received and that are assigned to you.

Coding Clarification Messages ButtonsNewClick New to open the Coding Clarification Message window where you create a new request and select your addressee from a list of providers associated with the hospital account. ReplyClick Reply to reply to a message with a status of Response Received.EditClick Edit to edit a coding clarification message that has been sent. You can edit only a new message that has not been read yet by the physician to whom it was sent. DeleteClick Delete to delete the selected message from the physician's In Basket folder if the status of the message is Request Sent. You cannot delete messages with a status of Completed. DoneClick Done to set the status of the message to Completed. If you have sent a message to a physician and then set its status to Completed, this action automatically removes the message from the physician's In Basket.

Coding Query Message WindowOn the Coding Query Message window, you specify details related to your request. For increased efficiency, the Providers section lists all the providers associated with the hospital account. Select the check box for your recipient and click the To button. You can also send messages to providers who are not on the hospital account. To create your message, you can use the SmartTools shortcuts available in the SmartTools toolbar. See the Using SmartTools topic in the Hyperspace Basics Guide.

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Additional Coding Information ItemsCoding statusDisplays the hospital account's current coding status.CoderDisplays the coder currently assigned to the account.

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Hospital Coding Info Form Toolbar ButtonsThe toolbar buttons on the Hospital Coding Info form allow you to perform various common tasks during the coding workflow. To have access to these buttons, you must have security point 43-MAY Code Account in your security classification.Except Coding Hx, these buttons are not available in the following circumstances: The account is closed, voided, or archived. Coding has not been started on the account (the account does not have a coding status).

Note: In this case, the Start Coding button remains enabled until coding has been started on the account.

Coding has been started on the account, but you are not the coder assigned to it. In this case, the Assign to Me button becomes enabled, and clicking it enables the form for editing.

The coding status has been set to Completed on the account. In this case, the Re-open Coding button becomes enabled.

The account is in use elsewhere. The account is not at the place of service for an IntraConnect deployment.

Hospital ChartClick to access a patient's hospital chart. This button is available only if you have the HB_CODER_ROLE assigned as your standard user role. Start CodingClick Start Coding to start the coding workflow on the account. Clicking Start Coding assigns you as the coder to the account, sets the coding status to In Progress, and allows you to edit the fields on the Hospital Coding Info form. In addition, any workflow action extension records configured to run at the start coding workflow point are fired at this time as well. Note: This button is enabled only if coding has never been started on the account.EncoderClick Encoder to launch a third-party coding system.Note: This button is not available for home health accounts. Pull InfoClick Pull Info to copy patient information from Registration/ADT to the ADT Info tab of the Hospital Coding Info form, where it is displayed as hospital account data. Note: Using the Pull Info button on either the Hospital Coding Info form or the Medical Records Abstracting form updates information on both forms. You configure the method according to which the system copies data in the Pull info copy method field on the Coding and Abstracting Configuration form in Hyperspace (Admin > HB Admin > System Profile Maintenance). Change StatusClick Change Status to access the Coding or Abstract window, where you can change the coding or abstracting status on the account. In the New Status field, you can enter a new status, and in the Comment field, you can enter a comment to accompany your change. Note: This button is enabled only if you are the coder or abstracter assigned to the account.CompleteClick Complete to set the coding status on the account to Completed. When you attempt to set the coding status to Completed on an account, coding validation checks are run. If the account passes the validation checks, the status is changed to Completed and the fields on the Hospital Coding Info form become read-only. If the account does not pass the validation checks, the Coding window appears, displaying any errors or warnings that occurred. If the validation checks return only warnings and no errors, you may still choose to set the coding status to Completed. Note: This button is enabled only if you are the coder assigned to the account.Coding HxClick Coding Hx to show the Coding & Abstracting Status History window, where you can see the coding and abstracting status change history for the account.Re-open Coding

Click Re-open Coding to set the coding status back to In Progress and allow edit access to the fields on the Hospital Coding Info form. Note: This button is available only when the coding status has been set to Completed. The user who re-opens coding automatically becomes the assigned coder on the account.Change UserClick Change User to open the Change Assigned Coder window, where you can assign a new coder to the account. The selection list from which you can choose a new coder only includes users with security to code a hospital account. The new coder you assign to the account appears in the Coder field on the Hospital Coding Info form.Note: This button is available only if you are the coder currently assigned to the account or if you have security point 299 in your security classification. Assign to MeClick Assign to Me to designate yourself as the user assigned to code or abstract the hospital account. Your name appears in the Coder or Abstracter field on the form.Note: This button is available only if you are not the coder or abstracter currently assigned to the account. Coding FlagsClick Coding Flags to access the Coding and Abstracting Flags window where you can review, add, and remove flags for this account.The Coding and Abstracting Flags window appears as read-only when you click this button in the following cases: Hospital account is closed or voided. Hospital account is currently locked, for example, by another user or a third-party encoder. In an IntraConnect environment, a remote hospital account is accessed at the guarantor's

home deployment.