<< Click to Display Table of Contents >> Navigation:  Grouper > Coding an Account for a Selected Patient

Once the Grouper has been accessed from either the Medical Records main menu or Charts, the Patient Summary will be displayed. The Patient Summary provides a summary of the coding entered on the account. It also displays the Finish Date and Revised Date, as well as the Computed DRG, Calculation Method and Receipted DRG.

 

 

Select Web Client > System Menu > Hospital Base Menu > Patient Account # > Medical Records > Grouper > Patient Summary

 

Patient Summary

 

 

•Finish Date: Displays the date that coding was completed on the account. The Finish Date and Coder name and login will automatically populate when Finish is select from the action bar. This field directly affects the auto-generation of insurance claims. If the Insurance Company Table page 1, M/R Complete field is set to Y, a Finish Date will be required before the claim will be auto-generated. This field also prints on medical record and insurance reports.

 

•Revised Date: Displays the date that revisions were made after the Finish Date was populated. The Revised Date and Coder Initials will automatically populate when Finish is selected from the action bar and the Finish Date has been previously populated. This allows the original coder's name and login and date to be retained and give accountability for revisions.

 

•Admitting Diagnosis: If an admitting diagnosis code is entered on the Diagnoses screen, it will be displayed in this field. If not, the system will default to the code entered as the Principal Diagnosis.

 

•Principal Diagnosis: The principal diagnosis entered on the Diagnoses screen will be displayed in this field.

 

•Principal Diagnosis Date: After a the principal diagnosis is coded, the principal diagnosis date will default to the patient's admission date but may be updated by selecting Edit on the Patient Summary screen. The diagnosis onset date will be captured to meet the Meaningful Use Healthcare Survey requirement.

 

•Principal Diagnosis Time: After the principal diagnosis is coded, the principal diagnosis time will default to the patient's admission time but may be updated by selecting Edit on the Patient Summary screen. The diagnosis onset time will be captured to meet the Meaningful Use Healthcare Survey requirement.

 

•Principal Procedure: The principal procedure entered on the Procedures screen will be displayed in this field.

 

•ICD9 Computed DRG: Displays the DRG that is calculated using the official ICD-9 coding guidelines. The DRG may be computed by selecting Compute on the action bar.

 

NOTE: A warning will appear if there is an interface between TruBridge EHR and any coding software. The interface information should be entered in AHIS page 6, M/R Code Finder field. When Compute is selected, the following warning will appear: “DRG and Reimbursement calculated through interface. Do you wish to continue?” A response of Y will continue with the calculation, and a response of N will stop the computation.

 

•ICD9 Relative Weight: Displays the Relative Weight associated with the ICD-9 Computed DRG

 

•ICD9 GLOS: Displays the GLOS associated with the ICD-9 Computed DRG

 

•ICD9 Reimbursement: Displays the expected reimbursement associated with the ICD-9 Computed DRG

 

•ICD10 Computed DRG: Displays the DRG that is calculated using the official ICD-10 coding guidelines. The DRG may be computed by selecting Compute on the action bar.

 

•ICD10 Relative Weight: TDisplays the Relative Weight associated with the ICD-10 Computed DRG

 

•ICD10 GLOS: Displays the GLOS associated with the ICD-10 Computed DRG

 

•ICD10 Reimbursement: Displays the expected reimbursement associated with the ICD-10 Computed DRG

 

•Calculation Method: This field will display a C if the DRG is computed in TruBridge EHR using the Compute option. This field will display an A if the DRG Autocompute option is used to compute the DRG from the Medical Records Print Report Menu. This field will display an I if the DRG was brought into TruBridge EHR from an Interface.

 

•Receipted DRG: Displays the actual DRG paid by the intermediary and entered during receipt entry

 

•Coding Status: Displays the current coding status assigned to the patient's chart.

 

•Page Orientation: Use the drop-down to select the orientation in which the Patient Summary will be printed in PDF format.

•Landscape

•Portrait