<< 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 the Home Screen, the Grouper 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

 

 

•Finish Date: Displays the date that coding was completed on the account. The Finish Date and Coder Initials 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 initials 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.

 

Some fields on the Patient Summary screen may be modified by selecting Edit on the action bar.

 

 

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

 

Patient Summary - Edit

 

 

The Finish Date, Revised Date, ICD-9 DRG, ICD-10 DRG and Receipted DRG may be changed on the Patient Summary Edit screen. It will also allow the Case Mix Group Code to be added.

 

•CMG (Case Mix Group) Code/Date: Aids in the filing of Inpatient Rehab PPS claims. The Date field is required by CMS. Enter the date of transmission of the IRF. This date will then be recoded in the Service Date/Assessment Date field on the UB04.

 

•State Submit Date: This field is used for New Jersey state abstracting.

 

•Chart Complete Date: This field is the date that all deficiencies were completed on the chart. For more information see Removing Deficiencies after Completion.

 

•Principal Diagnosis Date: This date will default to the patient's admission date, but may be changed here.

 

•Principal Diagnosis Time: This time will default to the patient's admission time, but may be changed here.

 

•Coding Status: This field is used to assign a Coding Status to the patient's chart. For more information see Adding a Coding Status.

 

Once changes are made, select Save on the action bar. Select the Back Arrow to return to the Patient Summary screen.