Home Forums Discussions Problems Double ICD-9 warning

It would seem as though this must have been asked or pointed out, but I haven't seen it so here goes:

Why does Amazing Charts warn you twice when you try to save a note without an ICD-9 code. There are times when there just does not seem to be a proper code. I will type one in manually, but without their being a code put in by the computer, you can't sign the note without clicking on "no" twice. Wouldn't once be sufficient?

Why do we have to sign in twice to enter to AC forum?

Romel:

Here is the answer to your double log-in problems:

Quick fix:
http://www.amazingcharts.com/ub/ubbthreads.php?ubb=showflat&Number=3735&page=3#Post3735

The explanation:
http://www.amazingcharts.com/ub/ubbthreads.php?ubb=showflat&Number=3736&page=2#Post3736

Courtesy of Bert, of course!

Bert:

I too have been troubled by all the alert signals and message boxes I have to click through in order to make Amazing Charts respond to my whims.

I REALLY wish that all those little warning boxes at the time of sign-off had that little check-box that says: "Never show me this message again."

I would check them REALLY HARD!

I would like to disable the billing template completely. I don't like the errors. I don't like the last page with the encounter form information, because I'm using a separate billing software system (Emedware by Sage).

Any one know how to disable the billing template altogether?

Both great ideas. Funny, because I have always looked for the workaround (Brian, did you know I like to do workarounds?), but the idea of skipping the whole page altogether, now that's a good idea. Over the course of the day, I could save tons of time. And, come to think of it, if you are looking for "Asthma, Cough Variant," it would be just as easy to type Cough Variant Asthma. With most of the codes, one has to type the first three or four letters anyway.

There is no advantage for the ICD-9 code to be listed other than possibly having it populate the orders. But, our radiology department will take Fever as quickly as Fever 786.1. (I think). And, it is good for our respective billers and coders to be able to go back and read the typed version of Hypercalciuria over the illegible written version. But, all in all, type it in, then click save, and it's done.

We need more preferences. I will say that Mr. Ed tells me that options and preferences are tougher than they seem.

Choosing an ICD-9 code (instead of just making up a diagnosis) has the advantage of populating the Problem List in the Summary Sheet, which also allows you to quickly fill your Assessment field at your next encounter.

I started out just typing in a diagnosis, but switched to ICD-9 codes, because I thought it would be good for me to get acquainted with the codes in case I ever did my own billing.

Now, there is one disadvantage of using an ICD-9 code as a diagnosis, in that ICD-9 codes are billing codes and they force you to pigeonhole your patients.

This degrades the transmission of medical information.

For example, there is no ICD-9 code for "Brittle Diabetic", yet that phrase speaks volumes to the next physician who sees your patient.

Reply #2"
Here's another pet peeve of mine, related to the ICD-9 search.

If you want to make that search feature truly handy, you need to do two things:

Leave out the non-standard abbreviations. It makes it wicked difficult to search for diagnoses.

Allow the search routine to search for words out of order, such that you could actually search for Variant Asthma Cough, or Cough Variant Asthma, or whatever, and come up with the right diagnosis.

That would be an advantage if "Hand, Foot and Mouth Disease" or "Fell, Scaped Knee" were a problem. But, they aren't. They are diagnoses on a face sheet. Personally, I don't want them in the problem list. I want problems, i.e. Asthma, Chronic otitis media, ADHD, in the problem list.

I guess I am a creature of habit, but I rarely use the ICD-9 dropdown box for a diagnosis. Probably should.

I'm understanding Brian's point of view (populating the problem list by using ICD-9 entries), but I'm not loving the ICD-9 code search engine. It's very very weak. But it's in the format of every type of ICD-9 search engine I've ever seen. The codes are written as they appear in the ICD-9 text book. This is biller/coder language, NOT doctor lingo. Try looking for 'sinusitis'.....good luck.

As I use a separate billing program, I do like the ICD-9 diagnoses showing up in my assessment (remember I also still print off my encounters). My front office person can pull the note out of the printer and transfer the ICD-9 codes to the superbill before I ever make it out of the room. Once I complete my part of the superbill it is on its way to the biller where it is then entered into the PM program. Duplication, yes, but it works for us.

Leslie

I have edited my ICD-9 code to fit my needs. I edit out words like "unspecified" and put diagnosis in the order I search "bronchitis, acute" (rather than "acute bronchitis"). I have taken out stupid codes like "Legal execution--suffocation from paperwork" and took out all the codes except for one for tuberculosis (there's 1,000's in there). Heck, there's only a need for 1,400 ICD-9 codes in my universe. I add on descriptions I use "dysesthesia or paresthesia" which the ICD cumbersomely puts as something like "Disturbance to skin sensation." The utility of the ICD codes are due to the hard work I have put in to modifying it into something usable-- the ICD-9 codes themselves are useful for sending out laboratory requisition, L&I forms that require ICD-9 codes and for billing.

I don't ever want to see my hard work editing overwritten by a default database.

BTW: Bert, I kept the code "fall into other hole", because I have this irrational fear of falling into the other hole-- If I accidentally do fall into this "other" hole, I'll just add a ICD9 code for "Fell into first hole" and attach a non-specific ICD9 code to that.
I also suspect that the "Fall into other hole" was created by the author of "Winnie-the-Pooh". Remember Piglet and Pooh falling into this "other hole" in the forest? And this occurred while under Rabbit's direction to search for his relative, Small. Now, I didn't see in the book that Rabbit had actually paid Pooh and Piglet a wage to search for Small, but I suppose he did. That would make it an L&I case, thereby necessitating this diagnosis code.

"Just my thought, if anybody cares." --Eeyore.

Good post, Roy.

I am also working on an improved ICD-9 database. Maybe we could share our improved ICD-9 databases, like we do our Med databases...

One thing I would like is if the original definition of the ICD-9 codes was displayed somewhere when I edit it. In case I mess up.

Another thing that would also *drastically* improve the ICD-9 database's functionality would be if you could link multiple diagnoses to the same ICD-9 code, so you could have, let's say, a "Brittle Diabetic" linked to ICD-9 codes for "Type II Diabetes, Controlled" and also "Type II Diabetes, Uncontrolled".

I can think of other applications for this, but I'm posting when I should be working. Gotta go!

Brian,
I believe that is doable. (multiple dx for same ICD-9 code).

I'm up for sharing (or giving away) my edited ICD9 codes without any liability waivers. But first I need to check if I am allowed to share my database without violating provisions of the current/previous EULA.

And suppose we are allowed to share this... Would this be done through FTP or through the e-mail attachment or through this website.

I am ready to learn, Sensei! I thought we could only change the name assigned to a specific numeric code.

We will wait for Bert, the Master of the Dojo, to answer the FTP questions.

I am game for this also! I had a pretty good, revised ICD-9 data base started a few updates ago. Then, when I updated AC it wiped out all I had done and replaced it with it's "updated ICD-9" database. Really irked me. I am still working to get that database back to the same useful level I had developed. I agree there are far too many useless abbreviations in the AC codes. Have at it, Roy.

Leslie

OK, and please correct me if I am wrong Roy. Remember, I do not use the ICD-9 codes, do not understand them, and think they are crazy. But, of course, I wanted to try. Just in case I wanted Acute Otitis Media and Otitis Media, Acute. Not sure if this will work -- I tried it 100 times. And, it may be a stupid way.

If you go to the chart and click on Find Diagnosis just as if you were going to pick a diagnosis, and ummm pick a diagnosis. Say Upper Respiratory Infection 465.9 (Sorry if wrong code)

If you have Upper Respiratory Infection in the Search Database, and you go to edit and type in URI and then 465.9 and click Edit, you will end up with URI 465.9, but the Upper Respiratory Infection will be gone. This is because it was it in the window and highlighted, et al. and the program thinks you don't like the name so it edits it. If on the other hand, you type an O in the top field, so that Upper Respiratory Infection disappears deep inside the cozy confines of Microsoft Access Land and then you type in URI and edit, you will now have 465.9 bringing up both. Don't ever use Add from my experiences. So, best I can do. Play around with it and see if Roy has a simpler and better way. I am sure there is.

FTP means you will need to upload the file to a site using an FTP client so that others can download it. Unless you have it set up, it is, in my opinion, not worth it. I would simply email, but if you have Outlook, you may have to tweak the registry at a Level1Remove or change the extension to .bmcd or something. The other alternative is to zip the file, which would be the easiest.

@Leslie...AARRGGHH!! Sorry about the overwrite. And, without going into my spiel about 85 backups --- I should mention when I talk about backups, I am talking about the mundane, day to day, backup in case something happens to your whole computer or AC. But, if you have a file (database) you have put a lot of work into as you had or one like Roy's or Brian's, then that one should be copied and put in several places. You can bet my AmazingMeds database is on the server but also on my home computer and burned to a few CDs. I dont know why AC would overwrite it. Databases shouldn't overwrite another database as another file may. It may be possible that the new one was structurally different. My recommendation would be that prior to any download, you back up the entire folder or at least rename the important databases, i.e. AmazingCharts and Codes or whatever from .mdb to .original or .old. This way AC won't know who the hell they are. It will just install and look at those weird files and say, "gee, I don't remember Jon making those, but I guess they can stay."

The other thing, and I am not saying that may way is the only way, but I never download a new copy onto the server. The server has my AC folder and that's all. There is no program on the server. All of the updates and upgrades are for the program functionality only and are installed on the clients where I then just tune to the server. Of course, this is assuming a client/server set up and not a peer to peer where the computer hosting the database is also in use. Of course, even in a peer to peer, the pseudoserver can still be used to run the program only.

Roy, great story on Pooh. Which reminds me. I will go find the story of Pooh on one of the journals done by a group of psychiatrists. It's incredibly funny. Of course, the comments the next month ranged form incredibly funny to my kid read that and was depressed for weeks.

Bert:

Tried what you suggested:

Opened a patient file, clicked on "Search ICD9s", clicked on "Add Codes".

Without selecting a diagnosis, I just entered in

"COTNERIASIS" (307.54)

and what I get is

"That code already exists. Please edit the code description rather than enter it again."

AARRGGHH!!

OK, so I uploaded The Winnie The Pooh Story to an FTP site. I didn't configure it so it is easy to get to. Too tired. But, if you follow these directions to a "T."

You will need I.E. 7.0

Go to:

ftp://riverviewpediatrics.org

That should get you to FTP Root at riverviewpediatrics.org

Click on the riverviewpediatrics.org directory

Click on html directory -- You should see the article, Pathology in the Hundred Acre Wood.mht. This is where it should let you right click and download, but it won't. I have tried left clicking, but it wouldn't open, but then I gave up after two minutes or so.

If you have I.E. 7.0, you can click on Page at the top right and select Open FTP Site in Windows Explorer.

You will get a logon screen:

Username: riverviewpediatrics.org
Password: password

This should open Explorer

Open the article or drag it to your desktop.

Let me know if there are problems.

Well, you've got to do whatever works for you in your practice. I respect your right to set up a system that is personally satisfying to you.

I gather you have devised a "face sheet" system for yourself, external from Amazing Charts, which demonstrates that you appreciate the value of having a problem list. You apparently just don't care for Amazing Charts way of doing it, and obviously don't mind doing double-entry to maintain it to your personal standards. There is absolutely nothing wrong with that; I just see an opportunity to automate that process here, and Amazing Charts is soooo.... cloooooose to perfection.

This inability to define each code with multiple descriptions may seem like a small thing, but in fact I believe it is a MAJOR OBSTACLE to proper use of the Problem List in the Summary Sheet, and limits users from realizing the full potential of this feature.

I SKINNED MY KNEE (ON THE ICD-9 DATABASE)

Take the "Skinned Knee" example that you offered above. To create an ICD-9 for that, you would have to find "ABRASION HIP/LEG" (916.9), and redefine it as "SKINNED KNEE" (916.9).

Well, what happens when the patient comes in with a "SKINNED HIP"? There is no clue left in the program as to which ICD-9 might correspond to that code. You wrote over it!

Well, you could just lookup 916.9 every time, and then type "SKINNED KNEE" next to it, but that doesn't save time, and it doesn't populate the Problem List.

The easier solution for many, as you say, is to just type "Skinned Knee" and have done with it.

MISSED OPPORTUNITY

Well, if it was a quick and painless process, and didn't obliterate the original code description, you might not mind doing a quick ICD-9 lookup for "ABRASION HIP/LEG" (916.9) and adding an alternate entry for "SKINNED KNEE" (916.9).

Now, did that save you any time in this encounter? Probably not.

However, next time a kid comes in with a skinned knee, you click on the ICD-9 button, start typing "SKINN", and up pops "SKINNED KNEE" (916.9), which gives you a happy feeling. The amount of time saved is marginal, but consider that a lot of the words we type are hard to spell, and not all the folks typing in diagnoses are brilliant physicians like me and you. With this system, they only need to be spelled right ONCE.

That is not all the benefit that accrues from using the ICD-9 code, however. I will not go into how having the physician select the ICD-9 code helps the person doing the billing (which may be ourselves in some cases).

The most important benefit accrues from the fact populates the Problem List in the Health Summary, and in the Assessment section of your Encounter Form.

WHO CARES ABOUT A SKINNED KNEE?

Now, you may say that "SKINNED KNEE" does not constitute much of an addition to the Problem List, but if you're scanning the Problem List, and "SKINNED KNEE" is joined by "SKINNED NOSE", "FIRST DEGREE BURN", "SCALP LACERATION", that may be a jumping-off point for a conversation about child safety, or something even more serious. It's good to have that kind of overview of past diagnoses.

I also hear your objection that the problem list could become cluttered with unimportant details, but of course these can be set as "Inactive" or even deleted, and they won't show up on the printed list or can be hidden in the display.

Lest anyone be distracted by the seeming-frivolity of skinned knees, remember that there are ICD-9 codes for "Other disorders" of the ear, brain, cervix, synovium with much more useful sub-diagnosis categories.

p.s. - Also, as you have indicated, using the ICD-9 codes creates one less "panic button" to click through when you're trying to sign your charts (admittedly this feature could be disabled for diehard non-coders).

Okay, so I can't follow instructions! Is that such a flaw in a physician?!!?

I tried it the other way you said, and it still didn't work.

This sounds like the batch file thing. Maybe tomorrow if you have XP, you can "invite" me over to your computer, and I can try. It should work. You pull up asthma, say 111.11, then you make it go away by typing another letter...ra or something, so you can't see it anymore. Then, choose Edit and type Asthma2 or something in the edit field. Type 111.11 in the ICD-9 code field in the Edit section. Click Edit. It ought to add the code. Now if you choose 111.11, you should see Asthma and Asthma2. hth.

Wow! Didn't see the post two above! Good thing there is email. OK, caveat. This is black and white and just having fun and giving opinions. So, no offense ahead of time.

No, I have no external method. The only external methods are FAP (wicked fast) and a possible Excel sheet. I don't even go there much. OK, so an admission. I would say in the last four years, I have looked at the summary sheet maybe eight times. Seriously. I won't count the immunizations, which is the only reason, I would look there. Never inactivated a problem. I'm not really upset with AC's version; I just think it isn't helpful -- to me -- anyway. I'm not much into face sheets, but at least AC prints a good one. I agree having diagnoses in a running continuum can help, but that is also the way the visit history is configured when I remember to change the chief complaint to the diagnosis. There isn't much thought into how it is designed.

Our medical students are mercilessly beated down when they screw up Problems with PMH, etc. A few years back, The POMR became the thing with the assessment and plan based on this. Patient comes into the hospital with three major problems and we deal with them. We don't deal with the appy he had ten years ago. So, to me anyway, there are major differences between PMH, Problem list and diagnoses such as an ear infection. In peds, the problem list is much shorter and the diagnosis list probably much longer. I don't know completely how to look at both the visit history (would look better as diagnoses) and a list of diagnoses. But, that is where I can see OM, scraped knee, OM, bronchits, OM, OM and go wow, this kid needs an ENT consult. And, one could easily argue that chronic OM would be an actual problem for this kid.

I wish there were a way to have these lists on the first sheet, but there probably isn't enough room. I have always wanted the summary sheet (if it were set up correctly) to come up first, forcing me to know a lot of this child already. I could go there when I went in the room, but being lazy I don't. I do know that the administrators at the hospital after ten years came up with a brilliant idea that has cut back delinquet computer charts by around 80%. Instead of the computer opening directly to the flow sheet where we all want to go, it opens to the Inbox. It is then easy to see your charts that need to be signed. They have also made the next sheet an incredible summary sheet. Very good design with what I believe will be better patient care.

I also trust my biller to come up with the right codes way more than the Access databases we have now. Some times it is nice to compare, but for the most part, that three inch thick book is just much more accepted by Anthem and Aetna than the codes we have now. I love the 786 and 786.00. I, for one, have never thought of Adam's idea until the other day. But, it is a good one. But, we all use the program differently; I have never inserted a diagnosis with the dropdown button and I have NEVER inserted an amount or a refill amount in a script using the dropdown fields. Just prefer typing I guess.

But, I get no benefit from the diagnosis going into the problem field. A single case of conjunctivitis or a mild ankle sprain just isn't a PROBLEM for me. And, the typed in diagnosis does show up in the assessment field on the progress note.

And, yes AC was heading toward something near perfection, but then the Johnny Quest factor (this should pull Paul into the discussion, lol ). That's my silly way of talking about the huge emphais on the interfaces such as Quest. A lot of people, maybe even myself but less so, are really looking forward to the PM. And, it may be great. But, it does take away from working on the little bugs or making more preferences.

This would be my breakdown of the three categories"

Diagnoses or flowsheet:

OM
Sinusitis
Eczema
Conjunctivitis
URI

PMH:

PDA closure at 2 weeks
Left ulnar fracture
RSV Bronchiolitis
Hospitalized: Gastroenteritis at 2
Appendicitis 9 years of age

Problems:

ADHD
Bipolar
Type I Diabetes
Chronic migraines
Appy w/adhesions
Allergic rhinitis
Eczema, chronic

This is key. I agree with this statement so much.

I wish Jon should refine these basic functions a bit and make AC into the killer app that it could be, before adding this kind of embroidery.

I wish Jon should refine these basic functions a bit and make AC into the killer app that it could be, before adding this kind of embroidery. [/quote]

Haven't many, many of us been saying this for quite some time? Get the basics down first.
Leslie

Yep, some of us ask about basics. I for one seem to be ignored on my comments about basics.

Obviously, I sort of brought this up, so I agree COMPLETELY with the above, but just to be fair, I suppose the little things would be there forever.

What I think would be cool if we could all sort of vote on things, although application development probaly doesn't work that way.

If Jon had the money (possibly read up the yearly to $800 or something -- don't shoot me), maybe there could be an interface team and an application development team. Microsoft (and I am not comparing AC to them, which is probably a good thing) has many, many teams of programmers working on different areas, which is probably why things get so buggy.

But, here's to a better immunization documenter and a script writer which documents allergies in real time and...

I must appologize to all of you providers, although many of you chimed in with me (Rainy are you listening), when I first started begging for the PM module over a year ago.

Although my memory on what we were told about the pending 4.0 is kind of hazy now, it looks like the PM part is going to be set-up in an AC services only fashion. Sort of like the back-up function that really should be able to do the same thing whether sending the data to AC's servers or opting to send it to a chosen source like a USB or networked drive. This is why I keep saying I too would be willing to discuss giving AC more so Jon can have a solid source of revenue to build his company and develop this product for all of us while designing it in a more user's choice fashion.

I forget if it was Wayne or not, but whomever it was, someone a long time ago posted a response to me about being careful for what one wishes for in terms of AC and the direction that the company and the product takes. This was back when I was making the pitch for the PM so we don't have the two to three vendor nightmares of working with the x-link, AC and some PM module. It was soon after the state based Rx's and the MidMark-Ritter interface. Now we use the ECG interface but we had already purchased that particular ECG way before we hooked-up with AC. Anyway, every since thing got really strange and stressed here a little over a year ago; and the more you folks keep talking about get the thing well polished before adding more major features, my mind keeps coming back to that insightful thought...

I gather most of us who have sent Jon and AC our biggest and best "Wishes" all have a bit of a role that we have played in this. The more I think about this the more I wish we really could have an AC convention, an "AC Meet", much like I do in my Mopar and Jeep hobbies, with Jon and his team. Hang out together, shoot the breeze, brainstorm while talking around a nice fire in the lobby of some nice lodge, over coffee and drinks. I think it could be really awesome. Goodness knows what might come from such a positive collaboration.

And I think it would help to clear up a number of things and give us all a feeling of being vested in this product and it's continued success, although I think many of us already do have those feelings sort of. AC is sort of a small version of Apple and Mac. Users who care more about the product they use, have a sense of a connection to it, and to varying degrees would want to actually be involved in the products design and development. Certainly most of the people here in present company fit this description. That's my two cents for what it is worth.

Jon, Vinny, AC are you listening???

Just downloaded.

Hmmm... Psych profiles on best-loved animal friends!

My favorite:

EEYORE

Axis I - Dysthymic disorder
Axis II - N/A
Axis III – Traumatic amputation of tail
Axis IV - Housing problems

Funny Stuff!

It is rather funny. I always check out the December issue of that journal. It is always dedicated to sartire. One of the articles was about the efficiency of how to wear a stethoscope, i.e. around neck, vs draping down vs in pocket. They studied the time it took to from resting point to listening to the heart. They are all rather funny.

Paul,

I believe it was I who told you to be careful what you wish for. Sometimes one may have a very good thing going and ruin it by trying to keep up with the Jones's. I really do not need many more (if any) new features. I would just be happy to have some of the old ones improved. I saw SOAPWARE transition from a reasonably priced, functional EMR to an expensive, "too-big-for-its-britches" program. That's when I ditched it in favor of AC.
Anyway, I love the idea of AC users sitting down and having coffee together.

Leslie

Starbucks?

Dunkin' Donuts?

Which one?

Ya know; How many times have we toyed with the idea of having an AC get together and yet it never seems to really go anywhere. Anybody really willing to take this bull by the horns??? I'd love to see Leslie's horses and property. How about an AC campfire retreat??? A little R&R combined with our favorite little EMR???

Hey, you all are welcome here! Paul could even go jeeping on part of the property. But dad-blame it I just gave up beer, cigarettes and steaks. What's left to do while you camp? Hmmmm, now there are some stalls that could use some attention and some downed trees which would benefit from a little chainsaw mastery and a whole lot of fences that need mending. OK.....PARTY AT MY PLACE THIS SPRING!!!

Leslie

Damn it Leslie, Next thing ya know, you're gonna have us all doing a good old fashioned Barn Raising too! Hee Haa Doggie!!! Hey Bert, you can bring your Jeep too and we can have a good old time get stuck in the gumbo.

Anyway, now that I've passed post # 666, I can rest a little easier.

I'll bring my Stihl and my Husqvarnas.

Okay guys, let me put my bid in here! After your lovely interlude with Leslie, you can all come out west and help me move to Sacramento. All the Two Buck Chuck and In & Out burgers you can handle!! It will probably be in the summertime, but I'm kinda afraid if Bert brings his partner, it (she) might melt. Oh well, there's a fun store in Old Sacramento that would be right up his alley (so to speak)(not that there's anything wrong with that)...

There we go with the Double Entendres again. And, don't even comment.