Coding and Abstracting is part of Epic's Health Information Management system and used to identify and define hospital services based on diagnoses, procedures, level of care, and other factors.

Resources

The following resources provide information on Coding and Abstracting functionality.

General

  • Completing Coding on an Account - (Handout) When coding is complete, this must be designated within Epic.

  • Enter Dialysis Start Date - (Handout) The dialysis start date can have an impact on the Medicare ESRD payment. Enter the dialysis start date on the Hospital Account Maintenance Abstracting activity.

  • Initiating Coding on an Account - (Handout) To begin coding an account, the coding must be initiated within Epic

  • Using Charge Capture (for Coders) - (Handout) Charge Capture can be used to enter charges that are not automatically generated by clinical workflows. The Charge Capture navigator section is set up differently by specialty in order to reduce the number and types of charges appearing in the list.

HIM Coding

  • Coding an Account (HIM018) - (eLearning: 7 min) Access a list of account workqueues, review clinical information, and complete coding on an account.

  • Coding Workspace - (Handout) Learn about the Coding workspace.

  • Customization for HIM Coders - (Handout) This document covers customization options and recommendations for HIM Coders. Topics included: Making Coding and Doc Review Activities Stand Out, Moving the Coding Activity: Floating Window, Moving the Coding Activity: Sidebar, and Customizing the Queries Sidebar.

  • Customizing the Queries Sidebar - (Handout) The Queries Sidebar is customizable. Topics include: Collapsing/Expanding the Queries Sidebar, Opening the Queries Sidebar in a Separate “Floating Window,” Returning the “Floating Window” to the Sidebar, Setting Default Workflow, Setting Group By Default, and Applying filters.

  • Entering Coding Comments - (Handout) Keep track of information related to the current account using the Comments tab in the Coding activity.

  • Entering Dates and Performing Providers for Procedures - (Handout) The dates the procedures were performed and the names of the providers that performed the procedures need to be entered directly into Coding Info.

  • Inpatient Query Opportunities for CDI Staff (HIM Coders) - (Handout) Queries are messages sent by coding staff to CDI (Clinical Documentation Improvement) Staff when more information is needed to complete coding on an account. They may be accessed and sent from the Queries Sidebar when coding an account. Sections included: Starting and Pending Queries, Viewing Queries, Replying to CDI Queries, and Deleting Queries.

  • Sending Coding Queries and Viewing Responses - (Handout) Coding Queries are messages sent by coding staff to providers when more information is needed to complete coding on an account and/or documentation-related deficiencies require resolution. They may be accessed and sent from the Queries Sidebar when coding an account.

  • Using the PasteBoard Activity - (Handout) PasteBoard is an activity that allows coders to copy and store information from notes and reports available within the Doc Review activity.

  • Working the Interim Billing Workqueue - (Handout) HIM coders may be responsible for working accounts that fall to the Interim Billing workqueues.

  • Workflow: Coding an Inpatient Account - (Handout) Inpatient accounts are grouped into workqueues based on different criteria set up within Epic. Supervisors determine which workqueues users will need to access. This document outlines the process used to code an inpatient account.

  • Workflow: Coding an Outpatient Account - (Handout) Outpatient accounts are grouped into workqueues based on different criteria set up within Epic. Supervisors determine which workqueues users will need to access. This document outlines the process used to code an outpatient account.

  • Workflow: CPT Coding Process for MOR/ASC Inpatient Procedure Coding - (Handout) Once an anesthesia log is posted for an inpatient account, the account will then fall to the UIHC HIM - ANESTHESIA CPT CODING: 2192 workqueue for specialized coding.

  • Workflow: HIM Coder/CDI Communication - (Handout) HIM Coders and CDI use Account Activities to communicate back and forth on accounts.

ED Coding

  • Abstracting Workspace - (Handout) Learn about the Abstracting workspace.

  • Accident-Related Encounters (Claim Information Record) - (Handout) For accident-related encounters, additional information needs to be collected regarding the accident. Claim Information Records keep track of information related to an encounter that is accident-related. A Claim Information Record must be created for the accident and attached to each encounter related to that accident.

  • Creating a Past Ambulance Encounter - (Handout) ED coders may be responsible for adding ambulance charges to accounts with Ground Ambulance Transportation charges. This document outlines the process for creating the encounter for these charges when the transportation occurred on a day prior to the day the coder is coding the account.

  • HB Coding Claim Edits - (Handout) How to work a HB Coding Claim Edit workqueue.

  • Initiating Abstracting on an Account - (Handout) To begin abstracting an account, the abstracting must be initiated within Epic.

  • PB Coding Claim Edits - (Handout) How to work a PB Coding Claim Edit workqueue.

  • Override a Price for an Unlisted Dental Procedure - (Handout) This document outlines the process for overriding a price on an unlisted dental procedure. This process can be started after coding has been started and ED Charging has been launched.

  • Updating Admission Type for Trauma Alerts/Activations When Coding an ED Account - (Handout) ED Coders may need to update the Admission Type when a Trauma Alert or Activation code is added to an account.

  • Workflow: Coding a Pure ED Account - (Handout) Accounts that have been admitted and discharged from the Emergency Department can be found in the UIHC ED - Uncoded Emergency Accounts : 12 workqueue.

  • Workflow: Coding an ED to Admit Account - (Handout) When a patient is seen initially in the Emergency Department but is ultimately transferred to an Inpatient or observation unit, the account can be found in the UIHC ED - Charge Capture Emergency : 157 workqueue.

  • Workflow: Creating and Coding a Past Ambulance Encounter - (Handout) ED coders may be responsible for adding ambulance charges to accounts with Ground Ambulance Transportation charges. This document outlines the process for creating the encounter for these charges when the transportation occurred on a day prior to the day the coder is coding the account. Once the encounter has been created for patients that were transported by ground ambulance, ED Coders are responsible for adding the ambulance charges.

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