EPIC EHR HELP

• On the Schedule tab you will have either your own schedule or the UNLV PEDS GENERAL DEPARTMENT (All Providers) schedule.

  • Medical students keep an eye on the Attending and Unassigned schedules

• You can create a room schedule if you like for the room (to help out your colleagues when you can)

• Filter By Status allows you to hide patients that are not here yet or checked out

Schedule Tabs (all sortable)

• • Dot Color: White (MA doing something), Green (Ready to be seen), Yellow (change when you go into the room), Blue (Orders to be done), Red (change when the family walks out of the room), Black (when they are checked out OR no show)

    • Always change this "digital flag" as well as the physical flag outside the room to keep clinic flowing well! FLAGS REVIEW

  • Time: Time the appointment is scheduled (reminder: the schedule is built so you are not expected to see a patient until 20 minutes after their scheduled time, for example a 12:40 patient does not have to be seen until 1:00, but if an MA or you can room and you can see the patient "on time" then you will buy yourself some time.

  • Status: Order= Scheduled, Arrived, Rooming in Progress, Visit in Progress,  Visit Complete, Checked Out, Signed

  • Status Details: Checked Out or Checked In (with time), and No Show

  • Patient Location: What room the patient is in

  • Patient, Age/Gender, REason for Visit/Call: Self explanatory

  • Visit Type: Walk in (acute care), Well Child (well child check), Follow Up (new acute care or follow up care from an ER, Urgent Care, Hospital Discharge or recent outpatient visit, New Patient (often a new well child check)

  • Notes:  Room number can be found here, the reason for the visit, if there are siblings being seen the same day, or other random notes made by the call center.

• You can always check and review the chart before the patient is roomed in, but do not enter any data, double click the note (which starts the encounter) as this may alter what the MA sees and affect your room color - leading to delayed rooming. 

• TIP: if you Right-Click a patient's name, then click "show appointment report" you can find out more information about the patient including demographics, time of booking, insurance.

• TIP: to take on a patient that was not originally scheduled for you (and to help out your colleagues!), highlight the patient and then click the "Change Provider" button at the top row of icons.

Click on the downward carat  🔽  to get options for well visits (of multiple ages) and a peds office general visit (for acute and other non well check visits).  Below are the "Note Writer Buttons" which is a 'smart' way to input patient information

• • HISTORY OF PRESENTING ILLNESS

    • Well Child Visit: List all parental concerns, recent illness, recent ER/Hospital visits on the main note page

    • Acute/Office visit: click the HPI tab first for the location of where to document

  • WELL CHILD # MONTH

    • Covers most all of the visit questions (ins and outs, safety, screening, social hx)

    • TIP: There are free text options, and you can carry information from the previous visit, and also create macros to move faster.

  • REVIEW OF SYSTEMS

    • Try to utilize the tab/smart text to help with your documenting

    • NEVER click “All Negative” for ROS/PE unless you really asked/examine it all (which you will not). This is fraud!

    • TIP: You can develop Macros to help your efficiency here 

  • PHYSICAL EXAM

    • Utilize the Physical Exam tab or type .physexam for the smart tools

    • You can use the EPIC HAIKU Mobile App to take pictures and HIPPA compliant upload them to the patient chart!

    • TIP: You can develop Macros (aka templates) to help your efficiency here 

• SUPER TIP:  press F2 to cycle through any missing template components

PROBLEM LIST

• • This is both an active and running list of diagnosis/problems that the patient has overall

  • Click the (+) button to add a PROBLEM to the VISIT DIAGNOSIS

  • Try to clean up this page as problems are resolved using the (x) button) (pick the best option)

  • Click the (△) button to change the diagnosis

  • Click the (double ˅) for more options: Details (to make changes), ⓘ to open a medline article, overview for an overall plan for this problem, "Current Assessment & Plan Note" (best place to document your A&P & always accept when done---then refresh your note for it to carry over), and Last Assessment & Plan (prior A&Ps if done properly)

VISIT DIAGNOSES

• • These are the diagnosis/problems which were addressed at the visit

  • prioritize problems as necessary.

Prescribing in House Medications/Vaccines

• • You can check the Immunizations tab for vaccines, but the WebIZ profile is usually more accurate

  • You can reconcile vaccines to keep them up to date in EPIC

  • TIP: Scroll down for recommended due dates on vaccines! but always cross check this with the CDC Schedule

  • ORDERED via +ADD ORDER "Preference List icon": There are TWO lists: Private insurances (Culinary, Aetna, Blue Cross, etc) and VFC (any Medicaid, Silver Summit)  go on right column (all vaccines available). Please be clear in your orders. Attendings MUST sign off on your vaccines prior to posting the orders. 

Prescribing Medications for Home:

• • Start with the [+ADD ORDER] or Preference List icon

  • TIP: if you click +ADD ORDER, then the + icon, then the Facility List tab, then the Database tab you will have access to all meds 

  • Please enter pharmacy into system and make sure to check the box on left to make it the permanent pharmacy (i.e. it will always be present when prescribing). 

  • All prescriptions should be entered in the EMR (regardless if e-prescribed, printed, or handwritten). 

  • Controlled Substances & Scheduled Drugs can be ordered the attending only, with a DEA number, and requires HOW MUCH PER DAY SCHEDULE AND THE ICD-10 Code

    • Stimulants CANNOT have refills. If you are providing multiple prescriptions (i.e. to cover for 3 months at one time), you MUST provide 3 separate prescriptions.

    • Narcotics must ordered by the attending only, with DEA. No refills can be given. 

  • Prescription pads are stored in the upper cupboard in the large physician’s workroom. 

  • Prescriptions WILL NOT print or send electronically unless you complete the sig/instructions, dispense amount, AND refill blanks. You must click the send/print Rx tab.

    • The duration section is optional and can be confusing. It is the duration of time the medication will stay active on the EMR in that patient's medication list but has nothing to do with your prescription. 

    • electronic sending rx's dont always work for residents, it is better to use the print option

    • scheduled meds must but under an attending only (no special paper needed)

    • TIP: the stacked three circles with three lines (looks like a comb or bulleted list), will open up pre-made list of orders

    • TIP: you can "edit multiple" for ordering labs to have them set for a specific lab; you can also make order sets to speed it up next time.

• • Must be entered into EMR through +ADD ORDER  and always connect to proper ICD-10 code. 

  • The EMR will not print out an order slip and will send it electronically, however you can reprint a physical copy upon request

    • to print a lab or imaging slip, click char review -> labs or imaging -> the test you want to print -> scroll down and click "reprint  order requisition"

    • IMAGING ORDER SLIPS MUST STILL BE PRINTED and sent home with the families

  • There is a list of the most common, but you can always search for more

  • Under “order details” make sure the order is under the attending, and with the lab/radiology clinic selected

  • ALL STUDIES Should be followed up by the resident who orders the test (TIP: keep an excel sheet, or add patient to a follow up list and check frequently). 

Where to send patients:

• • • See the FRONT PAGE for where to send patients go

    • We prefer Quest because it interfaces with our EMR and Desert Radiology because we have online access to images/reports although insurances may prevent this (ask Kathy if not Medicaid).

      • Culinary can only go to Clinical Pathology Labs (CPL) and Desert Radiology, all other insurances have no restrictions.

      • Uninsured patients can get deals or payment plans at CPL and Desert Radiology

      • Steinberg no longer accepts Amerigroup Medicaid (Send Amerigroup to Desert Radiology instead)

      • CPL is preferred for Amerigroup, Culinary, MGM, Silver State

Obtaining Results:

• • • SEE THIS LIST (click the "preferred services tab")

    • Check if there is any scanned documents or mentioning of results in previous notes/addendum.

    • Check alphabetized accordion folder in work room for previously faxed/mailed but not yet scanned/reviewed results.

    • Ask attendings or Kathy to access Quest, CPL, Lab Corp or Desert Radiology online records, call the offices yourself, or ask nurse/MA to track down results from desired location.

    • Request results to be scanned into EMR chart ASAP by nurses or medical records. 

Referrals are made when we have exhausted our expertise and capabilities as general pediatricians.  The referral process is as follows: an order is made on Epic and goes to our referral specialist's inbox.  She will call their insurance to make sure the specialist or service is covered by the patient's insurance.  Then she will call the family with the phone number of the specialist or service's office to make an appointment. This entire process may take up to 5 business days.  It is vital that you explain this process to parents, that the parent's contact numbers are correct in EPIC, and that you complete your orders and notes timely and accurately.

Ordering

• • Most all referrals are ordered in Epic, but there are a few exceptions below

  • To order a referral: +ADD ORDER then type in the sub-specialty you want, or click the Preference List icon

  • Always select "outgoing referral"

  • the DIAGNOSIS must correlate with the place of referral.

    • WCC  (Encounter for routine child helath examination without abnormal findings) can NEVER be used.

    • The Diagnosis should be under the problem list

  • if its a specific doctor, make sure to make note of it in the free text box. Carmen will do her best to match this doctor, BUT if the patient's insurance does not cover the practice, an alternative doc referral will be made.

  • ALWAYS write a brief summary of why you are making the referral (in the order) AND justify your rationale for referral (in your note)

    • Some referral orders have templates, only fill this out if applicable.

  • Decide if it is routine or urgent

    • if URGENT give the referral order printout directly to Carmen AND the note must be signed and completed by you AND the attending (so give them a gentle reminder)

    • ROUTINE referral order printouts can be discarded in the shred box

Involving Parents

• • Confirm their contact information before they leave

  • Inform parents in person (and write it on your AVS) that it may take up to 5 business days to process

    • Use the micro/quick text .DPSREF in the AVS instructions for a quick text about referrals.

  • If the parents are back for an appointment and have not had their previous referral process, let Carmen know and she can complete it that day.

Documentation

• • Be as detailed as possible in your HISTORY, PHYSICAL and PLAN.

  • If it is an URGENT complete the note before you leave clinic and remind your attending to cosign your note

Specialty & Service Specifics:

• • • Adolescent Medicine

      • Do NOT refer for therapy alone, but its okay for pharmacotherapy

      • You can directly refer for Nexplanon implantation but you must discuss and explain the procedures and possible side effects.

    • Behavioral Health, Psychology, Psychiatry, Neuropsychology: Please indicate SPECIFICALLY what you need, e.g. ABA therapy, otherwise all these department specialties populate 

      • Please give any FA-11F (Autism DX) form to Carmen. (with an attached scored CAST or MCHAT)

      • See this section for more information on ABA referrals

    • Child Find does not require referral (or insurance) but information pamphlets are available for parents to contact the service.

    • Nevada Early Intervention Services (NEIS), does not require a referral form HOWEVER completing the paper form helps to expedite the process. 

      • Generally, their services are for when milestones are delayed >50% in one area or >25% in two or more areas

      • Drop this form off with Carmen

    • Dentistry, and Optometry do NOT require referrals but information pamphlets are available. Parents are encouraged to call the number on the back of their insurance card to determine which services are covered.

    • Postpartum Anxiety and Depression:

      • We are working a formal protocol and in house services, but for the time being we recommend:

        1. Taking time to discuss postpartum anxiety and depression with the family

        2. Encourage that the family seek help either from their OB, therapist, help lines (give them the information card), or to schedule an appointment with Family Medicine downstairs

        3. Have them complete a PMAD Follow up Form HERE which can be given to Shelly to send to the Nevada Maternal Child Health Coalition to help us follow up on these families

        4. Continue to follow up at every well visit.

    • Podiatry Referral for Flat Feet, see this document

PATIENT INSTRUCTIONS: what you want to communicate to the families here

• • • Click "Go to clinical references" which have patient instruction templates (suggested and searchable and in multiple languages) you can add to your AVS (if you click add to patient instructions)

      • TIP: if you have coded a diagnosis in the plan, you will get options for handouts 

    • AFTER  Visit Summaries (formerly clinical visit summaries)

      • Must be printed for every patient as a summary of the visit, it is a communication to the family and to the front desk. 

      • Must include: 

        • WHEN they should follow-up, WHO to follow up with, WHAT reason 

        • (e.g. “Follow up with Dr. XYZ at 2 months of age for Well Child Check”). 

        • Any extra time needed for complex patients or language accessibility

      • This will help the schedulers ensure continuity.

      • An AVS Should be a brief summary in layman’s terms and no abbreviations of their visit and your plan. You can put whatever you want to communicate to the patient in these forms, and you can also pull in patient instructions here.

        • You can use the free text box on at the patient instruction side  or use the FOLLOW UP: when and who to follow up with

          • TIP: you can make buttons for when, why, and who here, e.g. Return in X-days (or approximate date), PRN, For: (customize here)

    • If Epic is down, you can print this AVS TEMPLATE to give to patients.

COMMUNICATION MANAGEMENT: for School Notes and other letters with the UNLV MEDICINE letterhead

• • • the default is a School Note but there are other options (click OTHER such: as allowing medication in school, asthma action plan, blank template, etc.

      • to make the box bigger to type in press F3 and a box will pop up

    • make sure to press the "+Add" button and choose the patient before you click "Send Now" (to print), there's also print now buttons available.

• • You can send reminders to yourself within the EMR under the “Remind Me” section. 

• LEVEL OF SERVICE: the CPT code of the visit and the level of complexity (see more in Billing and Coding Section below)

  • CHARGE CAPTURE: additional CPT codes for procedures done in clinic (e.g. vaccine administration, POC-testing, Screening Questionnaires, etc)

    • TIP: click the wrench to customize this

Located in the "WRAP-UP" Tab

Updates:

• • As of 6/8/20, you will no longer need to add the GC or GE modifier, a change has been made in EPIC to add this automatically when you are assigning an attending to your encounter.

  • The "25" Modifier - AAP Article

    1. The E/M service must be significant. The problem must warrant physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.

    2. The E/M service must be separate. The problem must be distinct from the other E/M service provided (eg, preventive medicine) or the procedure being completed. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.

    3. The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.

    4. Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).

    5. The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.

  • Always have a Chief Complaint that matches your visit (edit this at the rooming tab - visit info sub tab) to help with billing

Definitions:

• • • ICD-10: (International Classification of Diseases, Tenth Revision, Clinical Modification) = the disease(s) you are billing for

      • try to be as specific as you can with these codes, such as laterality, chronicity, etc.

      • Remember, each ICD-10 diagnosis code (top right corner of order page) needs to be matched with a CPT code 

    • CPT: (Current Procedural Terminology ) = the procedures/services/testing/questionnaires & visits you are billing for

      • Visits are broken down into ACUTE/PROBLEM or PREVENTATIVE CARE which is then broken down by NEW or ESTABLISHED patient; the third type of visit in clinic are CONSULT visits. 

        • A NEW patient is one that has never been seen in our gen peds clinic before (ie. has NO paper chart and NO previous EMR entries) OR has not been seen in >3 years. 

        • UNLV patients are NOT considered new if they were seen at Lied when we were UNRSOM in the past 3 years.

        • A CONSULT code should NOT be used in general pediatrics clinic (only subspeciality) - however scenarios for a consult code in a general peds clinic include dental and surgical clearances

          • in this instance you must include the THREE R'S:

            • R - Request for Consult (must be in the HPI with which Physician or Dentist is requesting)

            • R - Reason for Consult (must be in the HPI/AP why the consultation is needed)

            • R - Report of Consult (the note must be printed and faxed/sent with who requested it)

      • Remember that ACUTE/PROBLEM visit (NOT well child checks/preventative medicine visits) are billed based on complexity. Here is a basic rule of thumb:

        • Level 1 – 5 Mins (Nursing Visit) – ROS 0 – Exam Systems 0

        • Level 2 – 10 Mins – ROS 0 – Exam 1 – Straight Forward 

        • Level 3 – 15 Mins – ROS 1 – Exam 2-4 – Low Complexity Medical Decision Making (MDM)

        • Level 4 – 25 Mins – ROS 2-9 – Exam 5-7 – Moderate Complexity MDM 

          • Any billing at Level 4 or 5 MUST HAVE an attending see the patient as well, therefore a GC modifier

        • Level 5 – 40 Mins – ROS 10-14 – Exam > 7 – High Complexity MDM

      • You NO LONGER MUST enter vaccine administration codes & their quantity (eg: 90460/90461) but the nurses/MA’s will enter the individual vaccine codes. 

      • Any counseling (nutrition, etc) >30 minutes must be documented and have a brief summary of your discussion

    • E/M Services:  A Category of CPT Code  are determined by the complexity of a patient visit and documentation requirements.

    • Modifier: these modify the CPT code to provide more information

      • REMEMBER: Only modify the first CPT code (visit code), AND Number Codes must be billed BEFORE Letter codes

      • Examples:

        • 25 - generally anything we do in addition to a visit (e.g. screening tests, procedures, NOT point of care testing)

        • 50 - use if the procedure is bilateral

        • You no longer have to use a supervision modifier as of June 10, 2020. BUT still be careful in how you are ordering and billing as the GC/GE is derived automatically from your choices.

Helpful documents/books on how to Bill & Code:

• • • UNLV: Professional Services Documentation and Coding Guidelines, Typical times for E/M Services, MDM Tool 

    • Coding at the AAP, AAP Coding in Preventative Care, AAP Article on Modifiers

    • Billing and Coding 101 by Dr. Shedlock for help on deciding codes

    • There are also Coding books & Printouts throughout the Physician work room

General Tips:

• • Billing and Coding Completed under the “Wrap-Up” section of the EMR. 

  • Billing should always be “authorized by” attending name NOT a resident’s.

  • Remember each ICD-10 diagnosis code (entered in the “Plan” section) needs to be matched with a CPT code (entered in the “Wrap-Up” section). The Charge Capture “General” section has many of the frequently used codes. 

  • TIP: You can click the star on your very frequently used CPT codes to save as “My Favorites.” and you can add modifiers as well.

  • TIP: You can use the wrench to arrange your frequently used ICD-10 codes in the “Visit Diagnoses” section of the “Plan” tab.

  • We recommend choosing your orders with your precepting attending, or reviewing them with the attending prior to submission, in order to maximize your accuracy and learning.

  • Attendings: 

    • UNLV Attending Attestations