Ability to enter in soft coding diseases and procedures codes directly to the patient’s encounter

In order to view a patient encounter in Abstracting window, it must be closed first. Then you can start adding charges in Abstracting during your H.I.M. data review.

This option is where your H.I.M staff will work. We offer an integrated coding application very easy to use, in addition to the internal searchable database within eCS as well as the ability to enter in soft coding ICD10 diseases and ICD10-PCS procedures codes directly to the patient’s encounter. In essence, you can charge the medical procedures now to the patient’s encounter, having to give someone else the duty to charge that service.

How to use it?

On the main screen

You can search by Patient Type, Status, Patient Name, MRN - Medical Record Number, Admit Date, Company - Insurer, Encounter number, Coding Status (Finished, Not coded, Processing) , or combinations of the search options, or partial combinations. You will also see listed your patients by recent discharge dates.

You can print a report considering filters selected.

Once you select your patient you will see the following sections (4):

Encounter Data

You can see two tabs

Encounter: you see the summary of the encounter and the editable fields. You can correct the patient encounter type, the dates, disposition codes, place of service. But neet to fill mandatory fields (marked with an asterisk).
Patient Encounter log: you see the summary of all changes log on Encounter tab but this only apply for encounter with Status is Closed.

2. Physicians

You can see the admitting, attending, referring where you can add or delete as necessary

3. Diagnosis

You can see two tabs:

Encounter diagnosis where you can see all the diagnoses added during patient care. You can add if you needed and modify information.
Diagnosis history shows all inactive, unresolved, unconfirmed diagnoses from both this event and past events and cannot be modified.

Notes: Type can be either blank, Discharge or Admitting.

4. Coding:

You can search for the ICD10 diagnoses, HCPCS/CPT/ACHI Procedures, and ICD10 procedures.

When coding Inpatients, you are able to Obtain the DRG (only if you have a DRG service-connected to ECS Cirrus).

When entering your diagnosis, you have the ability to re-sequence them by simply clicking the diagnosis up or down. You can also assign your POA as appropriate per DX (diagnosis).

Type of Diagnoses that could be added previously on Diagnosis (see above) or by physicians on Physician Dashboard, will appear on Coding tab, Coded Diagnoses subtab:

Where:

If they were entered by Physicians:

MI : Medical Initial or Admitting

MF : Medical Final or Discharge

If they were entered in Coding window:

CI : Coder Initial
CF : Coder Final

Other types:

Other : OT

You can switch between those types by selecting any diagnosis and changing its type as seen below.

Note: To group diagnoses into the proper DRG, you need to identify a Present on Admission (POA) Indicator for all diagnoses reported on claims involving inpatient admissions.

Professional Coding, when the encounter is Outpatient (ambulatory) you are able to enter in the procedure/charges for the physician services. If the charges are already there, you assign the provider that performed that service and assign the DX pertinent to the service.

Now you are ready for send to NPhies for autorization.

When you are complete with coding you are able to mark the professional and institutional coding as “Completed” and now will be considered with status as Finished.

If you need additional information to complete a section, just save the register and it will stay as “Draft”.

In case you need more information on Coding & Abstracting, here is the link to the US CMS rules and guidelines for Coding.

Updates.

December 6, 2021. New update will now show charges code on Coding field section.

Please answer the following question, we appreciate your feedback.

Thanks.