Manually Coding an Admission (for 3rd party tool)

This describes the process to manually code an admission. Coding of an Admission can be completed in two ways:

• Via the Patient record
• Via the Clinic location

To complete the coding, the coder (or staff member) manually updates the DRG code details against the patient admission. This requires the use of a 3rd party product (external to CareRight) to determine the correct DRG code. An Admission is considered "Coded" once it has been discharged and has been grouped (the DRG (diagnosis_related_group) updated. This process assumes the patient has been discharged.

System Administration Setup

To ensure that the user/coder has access to the Admission Details summary page via Locations, the "Can edit ATS details" permission/privilege setting needs to be enabled via Users and Groups.

Via Patient Record

1. From the CareRight Dashboard.
2. Select Patients from the menu.
3. Enter the patient name/mrn etc. (e.g., John Smith).
4. Select Search button, matching account will display.
5. Select Show button to access the Patient summary and menu.
6. Select Admissions menu item, the Active admissions & Admission history will display.
7. Select the ARN (Admission Record Number) link to open the admission details.
8. To complete the admission for coding it requires the following to be updated:
   1. Diagnoses
   2. Procedure
9. Select the Edit Admission button
10. Scroll down through the admission to add Diagnosis & Procedures.
    1. Note: These values can be added dynamically, start typing each code into the relevant field. You can add multiple codes.
11. ‘Update’ the Admission
    1. The admission is ready to be grouped.

Grouping the Admission (Manually)

If you are coding manually, you will need to utilise your 3rd party software to obtain the DRG code.

1. To manually add the DRG code in CareRight, you need to edit the Admission.
2. Select the Edit Admission button, scroll down to the Diagnoses section.
   1. The Grouper Version will default to the value set in System Administration.
3. Enter the DRG code into the Diagnosis Related Group (DRG) field.
4. Scroll to the bottom of the page and click Update.
   1. The admission is now considered to be grouped.

Via Location

This approach allows for the coder to access all patient admissions to be coded from a central area.

1. From the CareRight Dashboard.
2. Select Locations from the menu.
3. Select relevant clinic location from the list.
4. Select Admission Coding from the menu.
   1. The Admission Coding Summary will display.
5. Select the count hyperlink, the Admissions screen will display. This screen will show all uncoded Admissions with relevant details including Patient name.
6. Click Select the ARN (Admission Record Number) link against each patient to open the admissions details.
7. Scroll down through the admission to update the Diagnosis and Procedure sections.
8. The admission can be manually coded as per the process above (via Patient).

Invoices and Claims

Uncoded / Ungrouped Admissions can also be accessed via the Invoices and Claims screen from the main CareRight dashboard. A message under the IHC claims table states: "Un-invoiced counts exclude Admissions that have not been coded/grouped yet” with a link to Admissions Coding Summary screen. 

Tips & Tricks

If you are accessing multiple admissions from the Admission Coding Detail summary, rather than click the ARN hyperlink (which takes you directly to the patient record). Follow these steps:

1. Hover the mouse cursor over the link and right-click.
2. Select Open Link in a New Tab — this will open a new web browser tab within the Patient Admission screen.
3. When done coding the admission, return to the original tab and repeat the process.
4. Between steps, click F5 to refresh the Admission Coding Detail summary.