Electronic Health Records15

Diagnosing (Physician)
Chapter 15
 Add a diagnosis to a patient
Key Concepts
International classification of Diseases
World Health Organization(WHO)
 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
ICD Codes
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)
 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
MedTrak enables physician to select
diagnosis for patient in many ways
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
Patient Diagnosis
 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
Selecting A Diagnosis Based On The
Presenting Problem
 Cursor in Diagnosis field of Visit Documentation
screen(Figure 15-1)
 Click DX by Checklist button to display Add Diagnosis
 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 Diagnosis
 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 A Diagnosis Based On The
 Another diagnosis search function:
 FIND DX by Description
 Click on Find DX button on Visit Documentation
 Diagnosis: Find screen appears
 Enter diagnosis description in Description field(Figure
Selecting A Diagnosis Based On The
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

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