36C25019R0093-022.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

December 2017 POLICY NO. 11-78-17

PATIENT CARE ENCOUNTER WORKLOAD

1. PURPOSE: To define procedures for the data capture process. This procedure will ensure accurate, appropriate, and timely data capture submissions that are appropriately reflected in the patient’s medical record documentation, encounter form completion, the Patient Care Encounter (PCE)/Automated Information Capture System (AICS) and when applicable, the third-party bill.

2. POLICY: The Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS) will maintain a consistent process of encounter management to collect ambulatory care data to support continuity of patient care, resource allocation, research, performance measurement, quality management activities, and third-party payer collections.

3. DEFINITIONS:

a. Outpatient Visit: The visit of an outpatient to one (1) or more units or facilities located in or directed by the provider maintaining the outpatient health care services (clinics, physician’s office, hospital/medical center) within one (1) calendar day.

Excluded are inpatients who receive care in an outpatient setting and patients who report only for pharmacy refills without an encounter with a clinical pharmacist.

b. Licensed Practitioner: An individual at any level of professional specialization who requires a public license/certification to practice the delivery of care to patients. A practitioner can also be a provider.

c. Non-Licensed Practitioner: An individual without a public license/certification who is supervised by a licensed/certified individual in the delivery of care to patients.

d. Treating Provider: A business entity that furnishes health care to a consumer;

this includes a professionally licensed practitioner who is authorized to operate a health care delivery facility. For Veterans Health Administration (VHA) purposes, a VA Medical Center, to include its identified divisions and Community Based Outpatient Clinics (CBOC), is the business entity furnishing health care at the organizational level. Sub-organizational level entities will include treatment teams and individually identified licensed and non-licensed practitioners. For purposes of the National Patient Care Database (NPCD), a Center for Medicare & Medicaid Services (CMS)-defined practitioner type field will be reported together with the Medical Center division code.

e. Encounter: An instance of direct, usually face-to-face, interaction or contact, regardless of the setting, between a patient and a practitioner vested with primary responsibility for diagnosing, evaluating, and/or treating the patient’s condition or

POLICY NO. 11-78-17

providing social worker services. Documentation of all encounters, including telephone encounters is required. Encounters do not include ancillary services or visits; nor do they include activities such as, but not limited to, taking vital signs incidental to an encounter for a physician visit. For VHA purposes, a telephone contact between a practitioner and a patient will be considered as an encounter if the telephone contact includes the appropriate elements of a face-to-face encounter, namely history and medical decision-making. A patient may have multiple encounters per visit. Collateral services provided as a part of a patient’s care (such as family therapy) will not be reported separately. Collateral services provided directly to the collateral (separate from the patient; for example, stress reduction skills) will be reported separately.

f. Ancillary Services (also known as Occasion of Service): Appearance of an outpatient in a unit of a hospital or outpatient facility to receive ordered services, testing, or procedures. An ancillary service does not include the exercise of independent medical judgment in the overall diagnosing, evaluating, and/or treating of the patient’s conditions. An ancillary service is usually the result of an encounter; for example, laboratory tests or X-ray procedures ordered as part of an encounter. A patient may have multiple ancillary services (occasions of service) per visit. Some ancillary services such as Lab and Radiology are automatically loaded to the database from other Veterans Integrated Systems Technology Architecture (VistA) packages.

g. Additions to the Provider File: Clinical services have provided lists of practitioners, both licensed and non-licensed, for entry into the provider file.

h. Person Class: This is a designation given to each practitioner in the new person file which grossly describes prescribing privileges and clinical function.

i. Encounter Reviewer: Clinic designee who ensures the process is followed and open encounters are appropriately and timely closed. Encounters not completed will be referred to management.

4. PROCEDURES:

a. All outpatient workload will be accounted for daily, meet the minimum mandatory data capture requirements (e.g., diagnosis, procedure, evaluation and management [E&M] coding, service connection [SC] determination, and provider), will be entered accurately in VistA and monitored for compliance. Noted deficiencies will be corrected and systems put in place to ensure optimal compliance. To qualify for workload credit, each encounter must be associated in the VistA system with numerous data elements.

b. Standard Data Elements of Encounter Forms:

(1) Procedure code from the Current Procedure Terminology (CPT);

(2) Diagnosis from the International Classification of Diseases (ICD);

(3) Patient: Person receiving health care services should include patient identification, including date of birth and Social Security Number (SSN) (or pseudo-SSN for collateral visits);

(4) Means Test/Eligibility: A current means test or eligibility status indicating that a means test is not needed;

(5) Date and Time of Service: The actual date and time that the encounter/ service was scheduled to occur. Time is a single entry indicating the time that the encounter was scheduled to occur. This information is taken from the Appointment Scheduling software, this data element will be identical in VistA and NPCD, but only reported when services are provided;

(6) Provider Identification and Type: The name of the treating provider and practitioner type (such as physician, nurse practitioner [NP], physician assistant [PA], etc.);

(7) Practitioner: VistA will store practitioner information by individual or designated group. Each practitioner will be designated with a defined practitioner type, such as physician, NP, PA, etc. Practitioner type will be stored in the NPCD;

(8) Active Problems: Problem/diagnosis treated that relate to the encounter (ICD-

10-CM). When more than one (1) active problem or diagnosis is designated for an encounter, the practitioner must determine which is the primary reason the patient sought treatment at that encounter. The determination of whether a treatment was related to an adjudicated SC condition or special treating authority will be based upon diagnoses treated during the encounter. VistA will maintain and store text descriptions along with coded values. Only the coded values will be transmitted to NPCD; and

(9) Service Provided: Services provided to the patient by the practitioner or treating provider. Nationally accepted coding nomenclature, such as CPT coding with modifiers and HCPCS (Healthcare Common Procedural Coding System) will be used to reflect all services provided by all practitioners. VistA will maintain and store text descriptions along with the coded values. Only the coded values will be transmitted to NPCD. Any CPT or HCPCS codes which accurately reflect the services provided during the encounter or ancillary service should be used.

c. Every outpatient clinic will utilize the electronic Outpatient Encounter Form for capturing required elements related to ambulatory care encounters.

d. The encounter form will be completed for all outpatients who report anywhere at VANIHCS, seeking any type of treatment or services, and for all inpatients who have scheduled appointments. This document serves as the primary source for collecting workload. The content on these encounter forms is nationally established.

e. All clinical care providers are responsible for selecting on the encounter form the four (4) data elements that are required:

(1) Practitioner;

(2) Problem/diagnosis(es) treated;

(3) Procedure and/or level of care provided; and

(4) Any special treating authority, (i.e.; SC/environmental contaminants/Agent

Orange/ionizing radiation determination/military sexual trauma [MST]).

f. Timeliness is essential to workload credit and data validation processes associated with this program. The outpatient workload will be transmitted to the NPCD daily and inpatient workload will be transmitted in a Patient Treatment File (PTF) up to seven (7) days following discharge or encounter.

g. Encounters reported must be adequately documented in the patient’s medical record by the appropriate treating provider in order to substantiate the type and level of care reported. The documentation should be extensive enough to justify the diagnosis and CPT code entered in the PCE package.

h. Clinics are expected to ensure the encounter is completed through the appropriate checkout of the appointment by the appropriate clinician within three (3) days, to allow for transmission and correction of any errors that may occur.

i. The encounter forms are updated quarterly per national guidance to ensure the codes displayed on the encounter forms are still in keeping with clinical practices and with any new releases of CPT and ICD coding systems. This review will be the responsibility of the Health Information Management Section (HIMS) and the Medical Administration Service (MAS).

j. Encounter Reviewer: Encounter Reviewers will be designated as follows:

(1) Patient Aligned Care Teams (PACT): The Medical Support Assistant (MSA) for each PACT will be designated as the Encounter Reviewer; and

(2) Service Chiefs/Program Managers will designate an Encounter Reviewer for the following Clinical Areas:

(a) Clinical Support;

(b) Compensation and Pension (C&P);

(c) Extended Care;

(d) HBPC (Home-Based Primary Care);

(e) Acute Care/Medical Specialties;

(f) Mental Health;

(g) Nursing Service/Chaplain;

(h) Nutrition;

(i) Seamless Transition;

(j) Social Work;

(k) Surgical Service;

(l) Prosthetics;

(m) Veterans Integrated Service Network (VISN) Telephone Triage; and

(n) PACT/Primary Care.

(3) When the designated Encounter Reviewer is unable to perform the responsibilities, a backup person must be assigned and trained to fulfill these duties.

k. Metric: No open encounters greater than seven (7) days from the date of treatment.

5. RESPONSIBILITIES: Refer to future state map, Attachment.

a. The Director will provide oversight and applicable resources to ensure the success of the Ambulatory Data Capture (ADC) Program.

b. Chief of Staff (COS) will ensure that all clinical services participate fully in the

ADC Program in relation to the development and appropriate utilization of encounter forms and collection of ambulatory care data.

c. Executive Leadership Team (ELT) members will monitor the twice-weekly

Encounter Action Required Report prepared by MAS and take necessary action to ensure accurate and timely completion of encounters.

d. Chief, Office of Information and Technology (OIT) will ensure that the Patient Information Management System (PIMS) and PCE software packages and patches are installed and operating in conformance with the software implementation schedule published by the VHA Chief Information Officer. They will ensure that adequate computer resources are available in regards to printers, scanners, workstations, hardware and technical support.

e. Service Chiefs and Program Managers:

(1) Ensure that all staff has been trained in the use of patient care encounter forms and participate in the ADC Program as a cooperative effort between administrative and clinical services. The goal is to ensure appointment entries, including cancellations and no-shows are completed on the day of the appointment and encounter forms are completed the same day as the actual appointment. All medical record documentation should support the coding information entered in the PCE software package;

(2) Clinical Service Chiefs who have program responsibility for ambulatory care data entry into the Medical Center VistA system will ensure that their staff enters data timely, accurately, and in conformance with PCE data requirements;

(3) Will monitor encounter form completion for all services provided under their service/program;

(4) Will designate an Encounter Reviewer and a backup to distribute action required reports; and

(5) Ensure that the Talent Management System (TMS) encounter module is assigned to all staff that has any responsibility related to the completion, monitoring or transmission of encounters.

f. Treating Provider/Practitioner:

(1) Complete an encounter form for all services provided in accordance with ambulatory data capture timelines;

(2) Selecting the four (4) data elements that are required -- practitioner, problem(s)/diagnosis(es) treated; procedure; and/or level of care provided; and any special treating authority; i.e. SC/environmental contaminants/Agent Orange/ionizing radiation determination/military sexual trauma) on the encounter form;

(3) Reviewing incomplete encounter reports and completing any necessary elements that may have been missed; and

(4) Completes TMS module annually. New employees will complete within 30 days of their start date at VANIHCS.

g. Encounter Reviewer:

(1) At the end of each clinic session, the Encounter Reviewer will run the

Encounter Action Required Report (EARR). Administrative action (no-show and/or cancellation) will be taken on open encounters prior to distributing to treating provider;

(2) The report will be promptly distributed to the providers/practitioners identified;

(3) Send list of action required encounters to treating provider’s Supervisor and

Service Chief of encounters that have not been completed within three (3) days from the date of service; and

(4) Send list of action required encounters to treating provider’s Supervisor, Service Chief, and ELT of encounters that have not been completed within five (5) days from the date of service.

h. MAS:

(1) Twice weekly prepare a summary report from the EARR and distribute electronically to Service Chiefs, Program Managers, ELT. The summary report will contain a link to the incomplete encounter list;

(2) Run daily the Incomplete Encounter Management Module (IEMM) and take necessary administrative action related to rejected encounters such as dual eligibility (Veteran/employee) or other encounter background elements; and

(3) Encounter forms are updated quarterly per National guidance to ensure the codes displayed on the encounter forms are still in keeping with clinical practices and with any new releases of CPT and ICD.

i. HIMS staff is responsible for providing technical guidance relative to the utilization of ICD codes, CPT codes, and HCPCS coding conventions.

j. The Medical Record Committee will monitor encounter completion trends.

6. REFERENCES:

a. Joint Commission Comprehensive Accreditation Manual for Hospitals

b. VHA Directive 1233, Closeout of Veterans Health Administration Corporate

Patient Data Files Including Quarterly Inpatient Census, dated June 14, 2017

7. RESCISSIONS: Medical Center Policy 11-78, Patient Care Encounter Workload, dated August 18, 2014.

8. REVIEW DATE: September 18, 2020

9. FOLLOW-UP RESPONSIBILITY: Chief of Staff

Certificate not trusted - One or ...

X Audrey L. Frison, DM, RN

AUDREY L. FRISON, DM, MHA, BSN, RN

Associate Director Patient Care Services Signed by: Audrey L. Frison 470550

Expired certificate

X Wayne Z. McBride, DO, MPH

WAYNE Z. MCBRIDE, DO, MPH

Chief of Staff Signed by: wayne.mcbride@va.gov

Revoked certificate

X Jay H. Miller

JAY H. MILLER

Associate Director for Operations Signed by: Jay H. Miller 290246

X John P. Shealey

JOHN PHILLIP SHEALEY, MBA

Assistant Director Signed by: people

X Michael E. Hershman

MICHAEL E. HERSHMAN, MHA, FACHE

Director Signed by: people

Link to Attachment

Attachment