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Pharmacy Paperless Refill
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Presenters:Angela Kihega, RHIT
Oklahoma City Area HIM Consultant
Amy Rubin, PharmDOklahoma City Area Clinical Applications
Coordinator
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Learning Objectives• Review the process for Paperless Refill from the
Pharmacist’s perspective.• Compare and contrast .9999 and 999.9 ICD-9 Codes as
they apply to Paperless Refill.• Fix UNCODED ICD9 Diagnoses/Operations for Paperless
Refill• Review and Complete Paperless Refills using the EHR
Coding Queue by Clinic Code• Understand the significance of Pharmacy 12:00 and 13:00
visits• Understand the use and sequencing of the V-Code and
Diagnosis Code
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Paperless Refill
• Electronic documentation of pharmacy only or outpatient clinic-initiated refill visits
• Automatically prompts the pharmacist to select POV for each medication refill processed
• Automatically populates necessary EHR fields to complete a pharmacy visit
• Not necessarily paperless
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Paperless Refill (Scenario 1)POV with Diagnosis “No errors”
1.Select PAPERLESS REFILL Option
2.Select POV from PROBLEM LIST– Inserts DIAGNOSIS from the PROBLEM
LIST as the SECONDARY POV– V68.1 is the PRIMARY DIAGNOSIS
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Paperless Refill (Scenario 1)
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Paperless Refill (Scenario 2)POV with an Uncoded Diagnosis of .9999 Code1.Pharmacist Bypasses selecting a Problem List DIAGNOSIS
– Then Pharmacist enters ^ (Shift 6) to FREE TEXT a diagnosis instead
2.Using a FREE TEXT diagnosis results in a .9999 Error Code as a Secondary Diagnosis3.Primary Diagnosis is V68.1
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PCC Screen shot of POV: .9999 (Scenario 2)
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Paperless Refill (Scenario 3)POV with a 999.9 (Complicated Med Care NEC/NOS)
1.Pharmacist bypasses selecting a diagnosis by using the Shift 6 (^) option
2.System automatically assigns a 999.9 (Complicated Med Care NEC/NOS) code as the SECONDARY diagnosis
3.Primary diagnosis is V68.1
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PCC Screen Shot of POV: 999.9 (Scenario 3)
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Pharmacy Visits12:00 vs. 13:00
• New prescriptions generate a visit with a time stamp of 12:00
• Prescriptions processed using Paperless refill generate a visit with a time stamp of 13:00
• Pharmacy visits can generate multiple visit entries for the same encounter– Ex: Same Day Visits with 12:00 and 13:00 time Stamp
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Same Day Multiple Pharmacy Visits
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Pharmacy Visits
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When to say NO to paperless refill
New prescription +Refill request = NO
at paperless refill prompt
This results in only one pharmacy visit … only one!
Optional: add POV for refills in EHR
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PCC Uncoded POV Report Menu
PCC Patient Care Data Entry Menu ...
DEU Data Entry Utilities ...
SUP Data Entry SUPERVISORY Options and Utilities …
ICD Fix UNCODED ICD9 Diagnoses/Operations ...
POV Fix Uncoded Purpose of Visit Diagnoses
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PCC Uncoded POV Report
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PCC/EHR Visit Audit
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Questions and Discussion