This section allows the auditor to review, edit, create, delete, or resequence diagnoses for the chart. The diagnosis section will intelligently determine what action the auditor has performed on the code and assign the most appropriate reason to the code. Changes to the code, the POA status, the sequence, or the query state will automatically request a recalculation of the DRG from TruCode and display these changes on the chart immediately
Code Entry and Display
The auditor can review, edit, and add codes here. Simply type into the blank area to enter a new code or type over an existing code to change it and then hit enter or tab. The code is automatically formatted into the proper ICD-9/ICD-10 format and looked up in TruCode. If a matching code is found, the description is added to the code description display (4).
Clicking this icon will look up the current code in TruCode. If a match is found, the description is automatically added to the code description display and the both DRG and reimbursement are updated. If no match is found or the code entry area is empty, the TruCode codebook will display with the closest possible match selected. The auditor can then click on the proper code in TruCode and have the system automatically add it to the chart.
The code description is displayed here. If it is a complicating condition or major complicating condition, an icon will display to the left indicating it as such.
The account status and reason is displayed here. The auditor can change the status by clicking the status text directly or by clicking on the Account Status/Reason Editor display button (7).
By clicking this, the auditor marks the code as requiring a physician query. The DRG is automatically recalculated as if the code did not exist on the chart and any reimbursement variances are noted.
Clicking on this displays the Account Status/Reason Editor. Please see the Account Status/Reason Editor section for a detailed explanation of that control.
This icon indicates that a change to the code has caused impacted the reimbursement amount. This icon can be manually toggled by the auditor by clicking on it.
Clicking this icon removes the code. Once removed, this icon changes to an arrow indicating that the code can be reinserted.
Newly added codes are deleted from the chart once the chart is saved. Existing codes that are removed are saved as removed in case they need to be added back at a later time.
