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Includes TSI 2015 Rheumatology Development for KBM 8.3
Encounter Copy Forward Template
NEW template for 2015
o Launched from “Copy Forward” buttons on *SOAP-TSI template
o Allows user to view HPI, Physical Exam, Assessment/ Plan, and Dictation data from
previous visits and copy selected data forward to current encounter
o Dictation Copy Forward feature no longer has a character limit (previous limit was 1000
characters)
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o Allows user to document BASDAI, calculate score, and graph results on the RHE
ScoreCard
o Score will display in Chart Note if completed on current visit
HAQ II
NEW template for 2015
o Launched from RHE ScoreCard or *Infusion-RHE
o Allows user to document HAQII, calculate score, and graph results on the RHE
ScoreCard
o Score will display in Chart Note if completed on current visit
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o New panel for Labs, Diagnostics, and Joint Injection history (after Medications &
Allergies panel)
o HPI, Physical Exam and Assessment/Plan panels:
MyPhrases can now be sorted by Summary or Phrase (will default to Summary)
When My Phrases Management button is clicked, Phrase Type will already be
selected on My Phrase Management template based on the area that you
launched from
New button to launch Encounter Copy Forward template
o Assessment/Plan panel - new links to “Joint Injection,” “SubQ/IM Injection,” and
“Follow Up” templates
(Continued on next page)
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Clients can now choose up to 3 documents to be generated when “Save &
Complete” button is clicked.
In the HPI and Physical Exam areas, clients can set default display to Dictation or
Grid, on a practice level or provider level.
Client can enable “Scribe Signoff” fields in the Signoff Panel if using scribes
These settings can be configured on *TSI for Rheumatology – Configuration
practice template.
Patient Problem Template
NEW template to allow for easier management of the Problem List
From this template, use can add new problems, edit existing problems, or add/edit problem
notes
Can be accessed from *Histories-RHE, *SOAP-TSI, or Assessment templates
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o “All Normal” checkbox now expanded to include the wrist, ankle, AC & SC checkboxes
on Joint Exam templates
o Comments box added for Skin
o Psych, Constitutional, and Head/Face areas – verbiage corrected in the Physical Exam
grid
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o “All Normal” checkbox adjusted to state “All joints non-tender and non-swollen”
o Normal joint summary statement has been condensed. It will no longer list individual
joints. It has been simplified to state “Exam of 28 (or 76) joints performed. All joints
found to be non-tender and non-swollen except those otherwise noted.”
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o Default Billing Preferences 2015 or 2014 Billing Option: Practices now have the option to bill injections
using the 2014 codes or the 2015* codes
*2015 code changes include:
20604—Arthrocentesis, aspiration and/or injection, small joint or bursa; with ultrasound guidance.
20606—Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; with ultrasound guidance.
20611—Arthrocentesis, aspiration and/or injection, large joint or bursa; with ultrasound guidance.
XS Separate Structure modifier(replaces 59 modifier)
o Bilateral Injection Billing Option: Practices now have the option to bill bilateral injections one of two ways:
One charge with a 50 modifier
Two charges (one with RT modifier and one with LT modifier) This option can be set on the *TSI for Rheumatology – Configuration template
o Small Joint (hands and feet) Billing Option Practices now have the option to bill small joint injections one of two ways:
With RT/LT modifiers
With FA-F9 and TA-T9 modifiers This option can be set on the *TSI for Rheumatology – Configuration template
o 51 Modifier Billing Option Practices may now choose to enable or disable the 51 modifier when billing
injections o Payer Specific Billing Preferences
If there are payer-specific billing preferences which conflict with the default billing preferences for the practice, practices can set payer-specific billing preferences for the following options:
2015 or 2014 Codes
Bilateral Injections
Small Joint Injections o Ultrasound Billing
If multiple ultrasound guided injections are performed, will only bill for one ultrasound (previously template would bill 79642 for each ultrasound)
o New Injection types added: Sacroiliac (SI) joint injection – listed in main Procedure menu Dupuytren’s cord injection - listed in main Procedure menu Sternomanubrial joint – listed under Arthrocentesis Intermediate Joint Sternoclavicular joint – listed under Arthrocentesis Intermediate Joint
(Continued on next page)
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TSI for Rheumatology – Joint Injection (continued)
Costochondral joint injection – listed under Arthrocentesis Small Joint Enthesis injections – listed under Tendon Sheath/Ligament and Tendon Sheath
Origin/Insertion Plantar fascia injection – listed under Tendon Sheath/Ligament and Tendon
Sheath Origin/Insertion Calcaneal spur injection – listed under Tendon Sheath/Ligament and Tendon
Sheath Origin/Insertion o Tendon Sheath injections
Can now document digit # for tendon sheath injections Tendon sheath location picklist now includes the word “sheath” for more
accurate documentation o Trigger Point Injection
Lumbar paraspinal has been added to the Trigger Point Injection popup o Crystal Analysis
If Crystal Analysis was performed on synovial fluid, you can now document results and bill for the Crystal Analysis
o Arrow Buttons Added arrow buttons to move injections from one line to another (this will
make the use of defaults much easier) o “Un-do All” button
This button will clear the Procedure billing grid and make fields editable again, so providers can adjust injection details even after charges have been verified (will need to Verify Charges again after making adjustments)
o Documentation Issues with documentation not appearing properly for the 3rd and 4th sites have
been resolved. o Additional Injection Sites
Providers now have the ability to document up to 12 injection sites on one visit User can navigate to Sites 5-8 and Sites 9-12 through tabs in top right corner
(See screenshots next page)
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TSI for Rheumatology – Joint Injection (screenshots)
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o User can now place order for injection (if injection not being performed same day)
o Thigh and abdomen added to site picklist
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The information contained herein is considered private and confidential material and is protected by US and International trade secrecy laws. Any duplication,
o Historical Assessment grid added so that user can select from historical assessments (not just Today’s Assessments)
o Providers can specify number of allowed infusions (this will enable a “count-down” feature on *Infusions-RHE template)
o When ordering an “Other Med”, user can now specify which infusion drug it is to be taken with.
o Separate comments box for Other Meds o Dosing information for weight-based drugs will now pass accurately to *Infusions-RHE
template
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o Ability to print PT order document on Save & Close (print box will auto-check when
order is placed)
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o Assessment is now required prior to placing order (this will ensure that Patient
Education appears correctly in the Assessment/Plan)
o New option for ACR handouts
TSI for Rheumatology – Follow Up
2015 enhancements include:
a. When user selects assessment, the system will automatically check the follow up box and place the current provider name in the “with” box (eliminates several clicks for the provider).
b. Follow up reason pick list is now rheumatology specific.
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Serves as a reminder that injections have been performed and 25 modifier
should be added to office visit charge.
Or, or if the Injections panel is empty, it may serve as a reminder that injection
charges need to be submitted.
There is a direct link to the Joint Injection and SubQ Injection templates in the
bottom right corner of panel so charges can easily be submitted if needed.
o When “Calculate Code” button is clicked, system will automatically add 25 modifier if
injections are performed during the visit (injection charges must be submitted before
the Calculate Code button is clicked).
o New configuration options:
Client can enable “Scribe Signoff” fields in the Signoff Panel if using scribes
Clients can now choose up to 3 documents to be generated when “Submit
Code” button is clicked. (Client must also set the configuration option to “Enable
auto-generating visit documents on Submit Code.”)
When “Calculate Code” button is clicked, system can automatically update
patient status in the inbox to “Complete” or other preferred status.
These settings can be configured on *TSI for Rheumatology – Configuration
practice template.
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o Link to HAQII has been added at the top o Fields added at top of template for documenting total visit time o Infusion Orders
User can now double-click in the Infusion Orders grid (so that infusion orders can be easily completed, cancelled, or otherwise updated)
o Medications Administered Dosing will now pull in correctly from the Orders grid (This will only work correctly for
orders placed after 2015 TSI Rheumatology content has been installed. To update dosing information on previously placed orders, there is an “Update” button available directly above the Orders grid which allows the user to quickly update the dose.)
If weight is updated on the infusions template (for example, if patient weight has changed since last office visit), and patient is receiving a weight-based drug, the total mg will update accordingly.
Tab order of fields is now correct (so user can easily tab from one field to the next, rather than clicking)
For drug orders placed in units of gms (such as IVIG orders), can now document Total Administered value in gms instead of mgs
Rate is no longer required Interval of Treatment is no longer required for Additional Meds Max Dose for Actemra - Template will not allow for the administration of Actemra
beyond max dose of 800mg Height field added Additional Comments field added “Documented by” column added (this field gets automatically populated with current
user name when the “Add” button is clicked) New configuration options available:
Disable auto-populating patients last Height and Weight
Disable auto-calculating total Mgs (Two Options: 1) all medications or 2) weight-based drugs only)
(Continued on next page)
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Height (displays in Infusion Administered section)
Rate
HAQ
Pain Score
Comments
Documented by (this field gets automatically populated with current user name when the “Add” button is clicked)
New configuration options available:
Enable uploading of infusion vitals to standard vitals grid Temperature is no longer a required field Reaction picklist has been updated Reaction field has been increased to 100 character Grid will now sort with oldest infusion at top, newest at the bottom. Sorting has been
fixed so that system recognizes that 1:00 PM comes after 11:00 AM (now based on military time).
o Pre Infusion / Post Infusion / Notes
Checkbox added to capture “IV stick performed by” Nurse Notes configuration option:
Client now has the option to use the Nurse Notes text field (which now has unlimited characters) or to use a Nurse Notes grid. The grid will capture time and user name of person who enters the notes. This option can be configured on *TSI for Rheumatology – Configuration template.
New checkbox added below nurse notes which allow nurse to send task to provider to review patient’s infusion visit.
MyPhrases - now have the option to sort by Summary or Phrase. Provider signoff checkbox has been added. Checkbox will add provider signoff to
infusion document and automatically regenerate document when clicked.
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NEW template which allows user to place an order for an infusion specific followup visit
“Smart” triggering to eliminate clicks for user
Launched from Follow Up button at button of *Infusions-RHE template
RHE Infusion Flowsheet Document
2015 enhancements include: o Infusions grid has been cleaned up:
Removed:
Rate
Concentration
Therapy Type Added:
Infusion #
Documented By o Infusion Orders grid
Will now show ALL active infusion orders, not just those placed on current encounter
Will sort with most recent at top. o Vitals grid
Now sorts in ascending order
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o Updated with panels and KBM 8.3 formatting to appear consistent with other templates
o Nurse Signoff and Provider Signoff checkboxes added
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o Disease Activity Measures from RHE ScoreCard will display in Chart Note
Patient Plan
o Cleaned up formatting, spacing and grids
o Meaningful Use compliant
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o Allows patient to complete pre infusion screening questionnaire with the NextPen
o Results populate into the TSI for Rheumatology – Pre Infusion Screening template
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