Diagnoses & Procedures

Diagonoses and procedures display in the bottom half of the Codes tab. The following information is presented for each:

Code Bubble—A color-coded icon that indicates:
- Whether or not the code is billable. The colors represent the following:
- - Blue = Established. This is a code that has already been documented in the chart. Any codes that are added to the Baseline state or imported from another system are billable without further documentation.
  - Gold = Speculative. This is a code that must be verified by a physician through a query. It is not billable.
  - Purple = Queried On. This is a code that has an outstanding query associated with it.
  - Brown = Incomplete. This is a code that has a resolved query attached to it but no code associated with the resolved query. It is not billable. The CDS must manually associate a code to the closed query in order for the code bubble to turn green and the code to become billable.
  - Green = Confirmed. This is a code that has been verified by a physician through a query response. It is billable.
  - Orange = Unreconciled. This is a code that displays in the Billed state but is not present in any previous states.
  - Gray = Previous Version. This is a code that was entered using a previous version of the ChartWise software. As soon as more work is done to the admission, the code bubble will change to the appropriate color.
  - White = Inactive. This is a code that was entered speculatively using a previous version of the ChartWise software but was not intended to be included in the Working DRG calculations.

Note: When a query is answered with “The subject matter of this query is not relevant at this time” or “Unable to Determine”, any code bubbles that were associated to that query will remain purple because the physician did not specify that code in the documentation. That code, therefore, is not billable.

Note: Placing your cursor over the code bubble displays the name of the person who added the diagnosis code to the list as well as the date and time it was added.

- The sequence number or principal indicator:
- - PDx=Principle Diagnosis
  - PPr=Principle Procedure
  - 2, 3, 4...n for secondary diagnoses and procedures
- Whether or not a diagnosis was present on admission:
- - Y=Yes
  - N=No
  - U=Unknown
  - W=Clinically Undetermined
  - blank = No POA provided by the user.
ICD Code—Shows the ICD code for the diagnosis or procedure.
Co-Morbidity/Complication—Co-Morbidity or Complication relative to the DRG. Indicates if the code is an MCC () or a CC (). A star icon () indicates that this code affected the DRG.
Hierarchical Condition Categories (HCC)—An HCC () icon indicates if the ICD code falls into a Hierarchical Condition Category. If you place your cursor over the icon, hover text displays the number and description of the category.
Note: There are several variables beyond the scope of this admission that will determine if this code is an actual HCC.
SOI/ROM Impact Indicator—An SOI ( ) icon indicates if the ICD code affected the SOI number. A ROM ( ) icon indicates if the ICD code affected the ROM number.
Elixhauser—A green Elixhauser icon ( ) indicates that this diagnosis code meets the criteria of an Elixhauser diagnosis.
Code Description—Displays the text description of the diagnosis or procedure.
Delete Button—Icon () that removes the diagnosis or procedure.

Highlighted Diagnoses & Procedures

As an option, your site can choose to have diagnoses and procedures that are present in the latest Working state but are not present in the Billed state to be highlighted in yellow. This aids in helping you locate missing codes. No action is taken on them. Highlighted codes are simply designated as “Missing in Billed.”

Change the Order of the Diagnoses & Procedures

At any time you can drag and drop a diagnosis or procedure to re-order the list by holding the row with the left mouse button, moving the row to the new location and then releasing the mouse button. ChartWise CDI will automatically recalculate the DRG.

As an option, your site can choose to have the secondary diagnosis codes with special designations (in other words, those that have icons or “badges” next to them) re-order automatically so that those codes are at the top of the diagnosis list below the principal diagnosis. With that option enabled, the order of secondary codes would conform to the following, where the presence of each code puts the diagnoses in this order:

MCC
CC
SOI Impact
ROM Impact
HCC
ECI

This is a hierarchy of codes, so that a code with an MCC (and any combination of other codes) will come first. Within each category, the codes will be ordered in alpha-numeric order. For example, if you have two secondary diagnosis codes, I50.1 and N39.0, both with CC badges, they would be ordered as:

I50.1
N39.0

Add Query

All speculative codes must be verified by a physician in order for them to be billable. The best practice for doing that is to associate a query to the speculative code from the Codes page. Click directly on the Code Bubble of the speculative code and click the Add Query link.

You are then taken to the Queries page where you can follow the instructions for creating a query.

Once the query has been submitted, the gold Code Bubble will change to purple, indicating that a query has been associated to that code.

Set the Present on Admission Indicator

To set the Present on Admission indicator on a Code Bubble, simply click directly on the bubble and select the appropriate choice from the POA drop-down list:

Once a POA has been selected, the Code Bubble displays it, as follows: .

You can also use the Set POA to Yes button to set multiple code bubbles at the same time. Refer to Set POA to Yes in the Codes Tab topic.

Add Procedure Details

To identify the physician that performed a procedure as well as the date and time the procedure was performed, click on the procedure’s Code Bubble. The following fields display:

Begin typing a valid physician name in the Performing Physician field. The system searches for a match and presents you with a list of choices. Select the appropriate physician from the list.

Next you can add the date and time that the procedure was performed by clicking the Set Date link. A date wizard displays that allows you to choose the date and time the procedure was performed.

Add a Diagnosis or Procedure

To add a diagnosis or procedure, click on the icon within the Diagnoses or Procedures labels, as follows

You are taken to the integrated TruCode Encoder Essentials page.

To add a code, type what you are looking for in the Search for field. Make sure that the proper code type is selected from the code books (in) drop-down list:

Diagnosis
External Cause
Procedure

Click the Search button. A list of possible topics displays in the Search Results box, and a specific code is highlighted in the Book box.

Use the scroll bars and click on the appropriate diagnosis or procedure. You also have the option to click the Show all # search results link to see additional results. The first code you select may require additional specificity. In the example above, if you click on 786.50, the following options display:

As you place your cursor over the appropriate code, you will notice that a plus sign displays, indicating that the code can be added to your current state:

Some codes also have Instructional Notes associated with them. To view the Instructional Notes, click the icon.

Click anywhere on the page to close the Instructional Notes.

You may notice a number next to some of the code descriptions. This indicates the Hierarchical Condition Category (HCC) for that code, as follows:

Once you have clicked on a code to add it, the new code displays in the state panel to the left of the search boxes.

You can drag and drop the diagnoses and procedures to select the principal diagnosis or procedure. ChartWise 2.0 will automatically resequence the list and recalculate the DRG.

Note: Although you can enter as many codes as you want, the maximum number of ICD-10-CM diagnosis codes that can be edited and grouped for an inpatient encounter is 50. Codes beyond that will not be edited or used in grouping/pricing calculations. A TruCode edit message will display letting you know that only the first 50 codes were used for calculating the DRG.

Research a Diagnosis or Procedure

When a code is selected in the Book box, you can view the following information associated with that code in the Research box to the right of the page:

Research—Provides you with relevant information from the Coding Clinics, Official Guidelines, Coding Advice and additional references such as Coders’ Desk Reference, CPT Assistant, ICD-10 Coding Handbook, etc. This information is very useful as an education tool and for audit preparedness.

DRG Analysis—Provides you with a possible alternative to your current state’s DRG.
(Not available for APR-DRGs.)
ICD-10—Provides you with ICD-10 codes that the selected ICD-9 code could map to.
Edits—Provides you with information relating to Medicare Code Edits, TruCode Edits and RAC alerts.

For a more in-depth look at the TruCode Encoder, please go to the TruCode Encoder Essentials topics.

Analyze the Diagnoses & Procedures

As you add diagnoses and procedures, you can click the Anaylze button to view a table that displays the DRG, relative weight, estimated reimbursement amount and Geometric Length of Stay (GLOS) for each code on the page if that code was the Principal Diagnosis. Click the Analyze button a second time to hide the table.

Note: The Analyze functionality is not available for APR-DRGs.

Expand/Collapse

The Expand button allows you to maximize the TruCode Encoder Essentials panes by hiding the application banners and tabs. Click the Collapse button to return to the complete page layout.

Remove a Diagnosis or Procedure

You can remove a diagnosis or procedure that you have added to the TruCode Encoder Essentials page by simply clicking on the button to the right of the code you wish to remove. The code will be removed immediately, the list resequenced, and the DRG recalculated.

Save the Diagnoses and/or Procedures That Have Been Added

When you are done adding diagnoses and procedures to this state, click the Save button to save your work and exit the TruCode Encoder Essentails page.

Note: You will not lose any of your work if you do not click the Save button. Clicking any tab will do the same as clicking the Save button.