S02 Attachment Twenty Eight 28 Medical Care Memorandum Number 548 136 376 Patient Care Data Capture.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-136-376

WEST PALM BEACH, FLORIDA May 23, 2017

PATIENT CARE DATA CAPTURE

1. PURPOSE: To establish policies, procedures, and responsibilities, to ensure accurate and timely capture of all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient billable professional services in order to support the continuity of patient care, resource allocation, performance measurement and improvement and improve third party collections.

2. POLICY:

A. All staff documenting encounters with patients must close out the encounter using the electronic encounter form.

Data should be captured on the same day as the note is written documenting the encounter, but not later than 7 days. No encounters may be recorded without documentation to support it.

B. All data concerning the provision of services in Veterans Health Administration (VHA) facilities will be recorded in accordance with the data element definitions included below.

C. Diagnostic Data on encounters will transition to the International Classification of Diseases (ICD) 10th revision on October 1, 2014. All data recorded on or after that date will use this code set. Until September 30, 2014, the 9th revision will continue to be used.

D. Provider taxonomies will reflect current licensure, certification, training or other credentials and data reported will be within the scope of practice for the provider’s taxonomy.

3. INTRODUCTION: VHA information systems have been modified to enable the transmission of all encounters (both inpatient and outpatient) from Patient Care Encounter (PCE) to the National Patient Care Database (NCPD) in Austin, TX. The data capture methodology consists of three elements: An appropriate procedural code (current procedural terminology {CPT-4}, Attachment Twenty-Eight (28)

36C24821R0092 appropriate diagnostic code, and practitioner identification.

Basic demographics, eligibility, insurance and provider taxonomy information is also necessary for successful transmission of the encounter to the NPCD.

A. DEFINITIONS

(1) Outpatient Visit: The visit of a patient to one or more outpatient units or facilities located in or directed by the Medical Center within one calendar day. Excluded are inpatients that receive care in an outpatient setting and patients who report only for pharmacy refills without an encounter with a clinical pharmacist.

(2) Encounter: An instance of care between a patient and a practitioner, who has responsibility for diagnosing, evaluating and/or treating a patient’s condition or providing social services. The practitioner exercises independent medical judgment. A patient may have multiple encounters per visit.

Telephone visits between a practitioner and a patient will be considered an encounter if the appropriate elements of a face-to-face encounter, namely history and medical decision making take place. Encounters do not include ancillary service visits, nor do activities such as, but not limited to, the taking of vital signs incidental to an encounter for a physician visit.

Encounter services must include the determination of whether or not a treatment was related to an adjudicated service-connected condition or treatment of conditions related to exposure and/or experience for (Agent Orange, ionizing Radiation, or Military Sexual Trauma, Combat Veterans, Environmental Contaminants) must be based on all conditions treated during the encounter and the entire encounter will be designated service connected or designated as being related to the special categories, if any treatment related to these conditions is provided. VistA maintains and stores text descriptions along with coded values.

Only the coded values are transmitted to NPCD. All encounters and encounter errors must be completed/corrected for workload close-out within 7 days of the visit. Data is transmitted to Austin nightly. Failure to comply will result in lost workload and revenue for the medical center.

(3) Telemedicine or Tele-Health Services: Telemedicine is generally described as the use of communication equipment to link health care practitioners and patients in different locations. This technology is used by health care providers for many reasons, including: cost efficiency, reduced transportation expenses, improved patient access to specialists and mental health providers, improved quality of care, and better communication among providers. For VHA purposes, a telemedicine contact between a practitioner and a patient is considered to be an encounter if the specific conditions are met as outlined in DSS instructions for Telemedicine. NOTE: Refer to VHA policy and instructions on Telemedicine and Telehealth Services.

(4) Collateral Services Collateral services are services provided to persons other than the patient as a part of the patient’s care (such as family therapy). They are not to be reported separately. Collateral services provided directly to the collateral (for example, to the spouse) separate from the patient must be reported separately for the collateral, i.e., stress reduction.

(5) Occasion of Service: An “occasion of service” is a specified identifiable instance of an act of technical and/or administrative service involved in the care of a patient or consumer which is not an encounter; that is, does not include the exercise of independent medical judgment in the overall diagnosing, evaluating, and/or treating the patient's conditions. Occasions of service are the result of an encounter (e.g., tests or procedures ordered as a part of an encounter).

A patient may have multiple occasions of service per encounter.

Some occasions of service, such as clinical laboratory and radiology studies and/or tests are automatically loaded to the PCE database from other Veterans Integrated Systems Technology Architecture (VistA) packages. To appropriately identify occasions of service, DSS identifiers are updated annually.

NOTE: Occasions of service replace the previously used term “ancillary services.”

(6) Active Problems: (why or purpose of visit):

Problem/diagnosis treated that relates to the encounter (ICD-9- CM). When more than one active problem or diagnosis is designated for an encounter, the practitioner must determine which one is the primary reason the patient sought treatment at that encounter. The determination of whether or not a treatment was related to an adjudicated service-connected condition, Agent Orange, Ionizing Radiation, Environmental Contaminants, Military Sexual Trauma, or Head and Neck Cancer will be based upon Primary Diagnosis. VISTA will maintain and store text descriptions along with coded values. Only the coded values will be transmitted to National Patient Care Database (NPCD).

(7) Provider: A business entity, which furnishes health care to a consumer.

(8) Licensed Practitioner: An individual at any level of professional specialization who requires a public license/certification to practice the delivery of care to patients.

(9) 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.

(10) Additions to the Provider File: Clinical Services are to provide lists of practitioners, both licensed and non-licensed, for entry into the provider file.

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

(12) Statistic Only (formerly known as workload only):

Situations may exist which are “workload only.” That is, they meet neither definition of an encounter nor an “occasion of service.” “Statistics only” clinics within the Scheduling application need to be set to non-count and non-billable. These are tracked for workload only (internal use), and are neither an encounter nor an occasion of service.

B. PROCEDURES

(1) Every outpatient clinic will utilize an electronic encounter form for capturing required elements related to patient care encounters.

(2) All electronic encounter forms will contain at a minimum, the three data elements that are required, i.e.

diagnosis, procedure and practitioner. Eligibility and insurance information are also necessary elements. In addition, applicable questions regarding service-connection, Agent Orange, Ionizing Radiation, exposure to environmental contaminants, Military Sexual Trauma and Head and Neck Cancer must be answered. Additional secondary diagnoses and multiple procedures should also be captured through use of the encounter form.

(3) All electronic encounter forms will be reviewed annually for coding content in accordance with any new releases of CPT-4 or ICD.

(4) Providers will enter all data into the electronic encounter form. All encounters and encounter errors must be completed for workload close-out within 7 days of the visit.

(5) Data validation of electronic encounter forms will be conducted to review the use and accuracy of procedure and diagnosis codes used by clinical staff, based on documentation in the progress notes, as well as the entry task performed by the provider. All clinics are subject to review. The number of charts reviewed is based on a sample size taken from the number of clinic visits for each clinic.

4. RESPONSIBILITY:

A. The Chief of Staff will ensure that all clinical services participate fully in the development and appropriate utilization of encounter forms and collection of PCD.

B. Service Chiefs will ensure that clinical staff document clinical information in a format that conforms to the software requirements for defining practitioner, the patient’s active problems, diagnosis(es) or reason(s) for visit, and the service(s) provided to the patient. Service Chiefs will ensure that administrative staff document patient demographics, the date and time of service, and the place of service in conformance with the requirements of the software. Service Chiefs will ensure that all staff have been trained in the use of patient care electronic encounter forms and participate in the collection and validation of PCD.

C. Practitioners are responsible to record on the electronic encounter form all required elements so that outpatient clinical workload is properly accounted for and the information is clearly reflected in their documentation. The practitioners are responsible to record at least one procedure code, one diagnosis code, and must review the computer-generated encounter form to properly answer the questions related to service connection and all mandatory fields, i.e. Agent Orange, Ionizing Radiation, Military Sexual Trauma, Combat Veterans, Environmental Contaminants.

D. The MAS ADPAC in conjunction with Chief, HIMS will provide oversight of PCD and ensure maximum utilization of electronic encounter forms, to include collection and maintenance of such. MAS ADPAC ensures that all clinics responsible for utilizing encounter forms review and update their encounter forms, no less than annually, to coincide with any new releases of National CPT and or diagnostic codes. This person will serve as the liaison for the Medical Center and the National PCD Program, and will relay all information regarding PCD to appropriate clinicians. This person will be the primary point of contact in determining changes to existing processes of PCD as it benefits the Medical Center. This person will be actively involved in the data validation process; establishing criteria for review of utilization and content of encounter forms and PCE management. Report/recommendations regarding PCD will be routed to appropriate committees for action. This individual will participate in all pertinent mail groups and VISN PCD meetings to ensure that clinical involvement remains a focal point in PCD.

E. The MAS ADPAC or designee is responsible to create and maintain electronic encounter forms. This will include interaction with any/all clinical staff that uses the encounter form. The Forms Creator will utilize the Automated Information Capture System (AICS) and the Patient Care Encounter (PCE) VistA packages to ensure that the process of PCD is maintained. This person will be responsible for remaining current on any new developments in PCD through the use of VA Forum mail and networking with other VISN 8 facilities. This person will also generate reports from PCE as needed and route reports to appropriate committees/staff.

F. Chief of IRM or designee will install all software and patches related to AICS and PCE. This staff will also be actively involved in the Technical Forum mail groups related to AICS and PCE.

5. REPORTING STRUCTURE: Not applicable.

6. REFERENCES:

VHA DIRECTIVE, 1082, Patient Data Capture, March 24, 2015 VHA Directive 1233, Closeout of Veterans Health Administration Corporate Patient Data Files Including Quarterly Inpatient Census, June 2017

7. FOLLOW-UP RESPONSIBILITY: Chief, Medical Administration Service (136).

8. RESCISSION: MCM 548-136-376 dated May 23, 2014.

Handbook 1907.03

VHA Directive 2007-030 dated September 27, M-1, Part 1, Chapter 5

7. EXPIRATION DATE: May 23, 2020

Donna Katen-Bahensky, MSPH Medical Center Director

Distribution: Electronic