Entering Patient Problems

In the Commure Pro on Android™ application, you cannot enter patient problems directly in the Problem List module (although you can view them there). However, every time you or another provider uses the application to enter a charge transaction, order, or clinical note for a patient, the diagnosis codes associated with that item are added automatically to the patient’s problem list, as described below. In addition, patient problems can come from other sources as well. In all cases below, the Commure Pro system keeps track of the date a problem was last used, so that providers can easily identify the most recent or chronic problems for a patient.

• Problems can be entered as the diagnosis on a completed charge transaction in the Charges module. (Problems associated with draft charges are not added to the Problem List.) See Entering Diagnosis Codes on a Charge Transaction.
• Problems can be entered as part of a completed clinical note in the Clinical Notes module. (Problems associated with draft notes are not added to the Problem List.) See Entering Diagnosis Codes on a Note.
• Problems can be entered as the reason for an order in the CPOE Orders module. (Problems entered as a “rule out” reason on an order are not added to the Problem List.) See Adding a Reason (Diagnosis) to a New Order.
• In the Commure Pro web application or the Commure Pro on Apple® application only, problems can be entered or modified for patients, independent of charges/notes/orders, directly in the Problem List module.
• Problems might be entered in your source system and then interfaced to the Commure Pro system.

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Selecting Diagnoses from Existing, Favorites, or Department Lists

There are several options that allow you to select diagnosis codes from a list. Each list contains different types of diagnosis codes, and can also include Search Terms. A Search Term is a partial code or phrase that immediately executes a search for a diagnosis code. Search Terms are preceded by a search icon so that you can distinguish them from regular diagnosis codes:. For example, if you select a Search Term called “chest pain,” the words “chest pain” automatically populate the Search field and all diagnoses containing that phrase are immediately displayed. Similarly, selecting a Search Term of “R07.8” would immediately show all diagnoses containing those numbers, such as R07.81, R07.82, and so on. Since a Search Term is essentially a short cut to executing a search, see Selecting Diagnoses Using the Search Option for more information about using the Search feature. The items that are included in each type of list are as follows:

• Existing: This option displays a list of the patient’s active diagnoses, which is pulled from the patient’s problem list history. How do diagnoses get onto the patient’s problem list? Diagnoses that you or others enter on the patient’s charge transactions, orders, or clinical notes are saved to that patient’s problem list. In addition, users can manually add diagnoses to a patient’s problem list in the Problem List module (on the web or Apple application). (The problem list does not include problems that were used on draft charges or as a “rule out” reason on an order.)
• Favorites: This option displays your personal list of favorite diagnosis codes and Search Terms, and is available only if your administrator has enabled this feature in your user profile. For instructions on how to add a code or Search Term to your favorites list, see Adding Items to your Charge or Diagnosis Favorites Lists and Saving a Diagnosis Search as a Search Term on Your Favorites List.
• Department: Below the Favorites list are a series of diagnosis Department categories. These categorized lists of diagnosis codes are created specifically for your department by your administrator to make it easier for you to find the codes you need. With Department categories, you progressively drill down through the categories to find the specific diagnosis code that you want. The diagnosis Department list can also contain Search Terms if your department administrator has added them to a Department category.

To select a diagnosis code or Search Term using one of the list options, follow these steps:

1. Start the process for entering a charge transaction or clinical note and then take either of the actions below:
   • For a charge transaction, tap ADD DIAGNOSIS

• For a clinical note, tap Search For Problems in a specific section of the note. The Add Diagnosis screen displays.

2. Review the available diagnosis codes in the options below:
   • Existing: Select this option to view a flat list of the patient’s existing diagnoses. The diagnoses that were used most recently are listed first.
   • Favorites: Select this option to view a list of your favorite codes and Search Terms. If you have created categories, tap a category name to open it and view th diagnosis codes within it. (See also Adding Items to your Charge or Diagnosis Favorites Lists.)
   • Department: Scroll down to see all of the Department categories. Tap a category name to open it and view the diagnosis codes or Search Terms within it.
   • (Optional) Tap More and then select Expand All or Collapse All to expand or collapse the Favorites and Department categories. All of the lists above show the HCC icon in the right column if a diagnosis code is designated as an HCC driver, meaning that it drives the revenue up in capitated Medicare Advantage plans.

Please note that diagnosis codes are updated each year. As a result, a code that was included on your Favorites or Department list in the past may be inactive today. Inactive codes cannot be added as new problems, so they are removed from the Favorites and Department list for service dates where they are not active.

3. Select each diagnosis that you want. You may select as many items, from as many options or categories, as you wish. When you select a diagnosis code, a checkmark appears next to it.
   • If you select a non-specific diagnosis, you may be required to refine it, in order to make the selected diagnosis as specific as possible. See Refining Non-Specific Diagnoses.
   • If you select a diagnosis that has associated secondary diagnoses, you may be prompted to select a secondary diagnosis. See Selecting Secondary Diagnosis Codes.
4. Tap Back when you are through selecting diagnosis codes. The main Charge Transaction screen or the NoteWriter screen appears (depending on your starting point), with all the codes that you selected displayed on it.

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Selecting Diagnoses Using the Search Option

If you cannot find the code you want in the Existing, Favorites, or Department list, you can use the Search option to search the entire master list of diagnosis codes. When searching for a diagnosis, you can enter any of the following into the Search field:

• A partial or complete diagnosis description
• A partial or complete ICD-10 code
• A partial or complete ICD-9 code (If you enter an ICD-9 code, the corresponding ICD-10 codes are returned in the results. This can be very helpful if you are not yet familiar with ICD-10 codes.)
• A partial or complete SNOMED CT® code The application uses a medical vocabulary called Intelligent Medical Objects (IMO®) to provide an alternate set of diagnosis descriptions in the search results. IMO is a patient-centric terminology database that is licensed through Commure Pro and it provides extensive mappings of disease states to ICD-9 or ICD-10 codes and any applicable HCC codes. Search queries involving IMO terms are limited to 100 results.

To search for a diagnosis code, follow these steps:

1. Start the process for entering a charge transaction or clinical note and then take either of the actions below:
   • For a charge transaction, tap ADD DIAGNOSIS

• For a clinical note, tap Search For Problems in a specific section of the note.

2. Tap into the Search field at the top of the screen and type a full or partial diagnosis code or a description. As soon as you enter at least two characters, any diagnoses that match the code or phrase that you typed are displayed in the Search Results at the bottom of the screen. As you continue typing, the list of results changes. When you are done typing, close the virtual keyboard so that you can see the full screen.

• At the top of the screen, the Filters sections shows a list of filters that you can use to narrow the results down to a more concise list of matches. Below that, the Search Results section shows a list of potential matches. You can tap the Expand icon at the top right corner of either section so that it fills the entire screen. When you expand one section, the other section is hidden. This feature is sticky — the section will remain expanded for this and future sessions, until you tap the Collapse icon to collapse it back down to its default size, and show again the section that had been hidden.
• If a diagnosis code in the Search Results is designated as an HCC driver, meaning that it drives the revenue up in capitated Medicare Advantage plans, an HCC icon is displayed in the right column.
  • If you entered a diagnosis code or description that has a single exact match, it is displayed and automatically selected for you (as indicated by a checkmark).
  • If you entered a diagnosis code or phrase that does not have a single exact match, then a list of potential matches is displayed. The list shows you the most relevant diagnoses first, based on the search term that you used. There are several options available to help you find the diagnosis that you want from the list of results:
• You can change the order in which the diagnoses are listed, so that they are instead sorted numerically by charge code, or alphabetically by description.
• You can use filters to narrow the results down to a more concise list.
• If this is an item that you search for frequently, you can save your search as a Search Term so that you can re-use later.
• If you select a non-specific diagnosis, you may be required to refine it, in order to make the selected diagnosis as specific as possible.
• If you select a diagnosis that has associated secondary diagnoses, you may be prompted to select a secondary diagnosis. For instructions on any of these features, see Additional Features for Selecting Diagnoses (for the first four items) or Selecting Secondary Diagnosis Codes (for the last item).

3. Select the diagnosis that you want from the search results, and/or perform additional searches as necessary (repeat steps 2 - 3). Or, if you cannot find the diagnosis you want in the search results, see Entering Diagnoses as Free Text.
4. Tap Back when you are through selecting diagnosis codes. The main Charge Transaction screen or the NoteWriter screen appears (depending on your starting point), with all the codes that you selected displayed on it.

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Entering Diagnoses as Free Text

If you cannot find the diagnosis that you want by looking in the Existing, Favorites, or Department list, or by performing a Search for it, you may be able to enter it as free text. You can add free text diagnoses only if your administrator has enabled this feature in your user profile. It is best practice to always search for a diagnosis, before adding it as free text:

1. Start the process for entering a charge transaction or clinical note and then take either of the actions below:
   • For a charge transaction, tap ADD DIAGNOSIS

• For a clinical note, tap Search For Problems in a specific section of the note. The Add Diagnosis screen displays.

2. (Optional, but recommended) Tap into the Search field at the top of the Add Diagnosis screen and type a diagnosis description. Review the list of search results, and if you do not see the diagnosis that you want, proceed to the next step.
3. Tap the Free Text button at the top right of the screen.

The Enter free text field is displayed and displays the text that you searched for (in Step 2) in the field. You can leave the text unchanged, or type a more informative description for the diagnosis you wish to enter.

4. Tap OK to save the free text diagnosis and go back to the main Charge Transaction screen or NoteWriter screen. The main Charge Transaction screen or NoteWriter screen appears (depending on your starting point), with the free text diagnosis displayed on it. On the Charge Transaction screen, the diagnosis is preceded by the words “Free Text” as in this example:

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Additional Features for Selecting Diagnoses

When selecting diagnoses from the Favorites, Existing, or Department list, or when Searching for a diagnosis, there are several tools at your disposal to either help you find the diagnosis you want by narrowing the list of possible matches, or to help you refine or enhance a diagnosis that you have just selected:

• After performing a Search for a diagnosis, you can tap More and then use any of several options to change the sort order for the list of potential matches in the Search Results section. See Changing the Sort Order for the Diagnosis Search Results.
• After performing a Search for a diagnosis, you can use the options in the Filters section to narrow the matches down to a more concise list. You apply the Filter options before selecting a diagnosis. See Using the Filter Option when Searching for Diagnoses.
• After performing a Search for a diagnosis, you can save the search that you just performed as a Search Term, so that you can re-use it later. Search terms are added to your diagnosis Favorites list, so that you can find them quickly. See Saving a Diagnosis Search as a Search Term on Your Favorites List.
• If you select a diagnosis that is not very specific from any of the Favorites, Existing, or Department lists, or from the Search results, you may be required to refine it to make it more specific. This automatic feature walks you through selecting a series of attributes from various categories. The refine feature is displayed after selecting a diagnosis. See Refining Non-Specific Diagnoses.
• If you select a diagnosis that has associated secondary diagnoses, you may be prompted to select a secondary diagnosis. The secondary diagnosis feature is displayed after selecting a diagnosis. See Selecting Secondary Diagnosis Codes.

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Changing the Sort Order for the Diagnosis Search Results

After typing some numbers or a phrase into the Search field (or after selecting a Search Term from the Favorites or Department lists), a list of potential matching diagnosis codes is displayed in the Search Results section at the bottom of the screen. If the list of matches is long, you can change the way it is sorted, to help you find the code you want more easily.

1. Perform a search for a diagnosis by typing a code or phrase in the Search field on the Add Diagnosis screen. A list of potential matches is displayed in the Search Results section at the bottom of the screen.
2. Tap More and then choose one of the following options
   • Sort by Rank (the default): Sorts the diagnoses so that the most relevant ones are shown first.
   • Sort by Code: Sorts numerically by code, in ascending order.
   • Sort by Description: Sorts by description, in alphabetic order. The diagnosis are sorted in the desired manner.
3. (Optional) Tap More again and then choose the same sort option a second time, to reverse the sort order. For example, tapping Sort by Description a second time sorts in reverse alphabetic order. You might do this if you knew the diagnosis you were looking for was near the end of the alphabet. Note that all future searches for diagnosis codes will be sorted in the same order that you last selected, unless you change it using the same steps as above.

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Using the Filter Option when Searching for Diagnoses

After typing some numbers or a phrase into the Search field (or after selecting a Search Term from the Favorites or Department lists), a list of potential matching diagnosis codes is displayed in the Search Results section at the bottom of the screen. You can then use the options in the Filters section to narrow the results down to a more concise list. By default, the application automatically applies the Age and Gender filters, so that the result list shows only those diagnoses that are appropriate for the patient, based on their age and gender. However, you can turn off these filters if necessary. For example, you might turn off the gender filter when searching for a diagnosis for a patient who is transitioning from one gender to another.

1. Perform a search for a diagnosis by typing some numbers or a phrase in the Search field on the Add Diagnosis screen. A list of potential matches is displayed in the Search Results section at the bottom of the screen.
2. Scroll through the filters in the Filters section at the top of the screen and apply one or more of the filter items below. You may use any combination of these filters (some filters may not be available).
   • Patient Demographics: Both the Age and Gender filters are turned on by default (note the checkmark next to each), indicating that only diagnoses for the patient’s listed age and gender are shown. To turn off either of these filters, select the filter, and the checkmark is removed.
   • IMO filters (names vary): A series of filters with varying names are displayed; these are IMO classifications by disease for the terms by which you are searching. For example, when searching for diabetes, you might see filters for trimester classifications for gestational diabetes.
   • Common Terms: A series of filters are automatically created based on commonly used terms found in the results. Only those diagnoses containing the specific term(s) that you select will be shown in the search results.
   • Clinical Areas: A series of filters based on specialty are displayed. Only those diagnoses that are used by the specialty that you select will be shown in the search results.
3. (Optional) You can tap the Expand icon at the top right corner of either the Filters section or the Search Results section so that it fills the entire screen. When you expand one section, the other section is hidden. This feature is sticky — the section will remain expanded for this and future sessions, until you tap the Collapse icon to collapse it back down to its default size, and show again the section that had been hidden.

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Saving a Diagnosis Search as a Search Term on Your Favorites List

If you find that you are searching for the same diagnosis over and over again, you can save your search as a Search Term, so that you can re-use later. In addition, if you used the Filter option when performing your search (as described in Using the Filter Option when Searching for Diagnoses), you can save that search criteria as part of your Search Term. The Search Term is added to your diagnosis Favorites list for future use. It is preceded by a Search icon so that you can distinguish it from regular diagnosis codes:

1. Perform a search for a diagnosis by typing some numbers or a phrase in the Search field on the Add Diagnosis screen. A list of potential matches is displayed.
2. (Optional) Use the options in the Filter section to further narrow the search results to a more concise list, as described in Using the Filter Option when Searching for Diagnoses. The list of potential matches in the Search Results section is updated. It shows only those results that match the criteria you selected on the Filter screen.
3. Tap on the gray Favorite button that appears at the far right of the Search field.
4. In the Enter search name field, give the Search Term a name (the phrase you used in Step 1 is the default name, but you can change it), and then tap OK. The Search Term is added to your diagnosis Favorites list for future use.

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Refining Non-Specific Diagnoses

If you select a non-specific diagnosis (from the Favorites, Existing, or Department list, or by Searching for it), you may be required to make the diagnosis more specific, depending on how your user profile is configured. If this is the case, the application walks you through selecting a series of attributes from various categories.

1. Select a diagnosis from the Favorites, Existing, or Department list, or by Searching for it. If the selected diagnosis is non-specific and your user profile requires that you refine it, then one or more diagnosis filter dialog boxes are displayed. Each dialog box shows a category (such as type, a complication, or a severity) with a list of attributes.

(If you select a specific diagnosis, or if user profile does not require that you refine non-specific diagnoses, the diagnosis is simply selected as is, and you are not required to complete the remaining steps.)

2. Select an attribute from each category as it is presented to you. As you select attributes, some attributes in other categories may no longer apply and are disabled (grayed out).
3. (Optional) You can change your previous selections by tapping the Back or Next buttons at the bottom of the filter dialog box.

Once the diagnosis is detailed enough, the filter dialog boxes close and the refined diagnosis is automatically added to the Charge Transaction or NoteWriter screen (depending on your starting point).

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Selecting Secondary Diagnosis Codes

When you select a diagnosis (from the Favorites, Existing, or Department list, or by Searching for it), the appropriate diagnosis code is added to the charge transaction or clinical note. However, in the case of some primary diagnoses, you should also select one or more secondary diagnoses, for full and accurate billing and documentation. The application always alerts you when one or more secondary diagnoses may be applicable. For example, when you select “Obesity, diabetes, and hypertension syndrome” from the IMO vocabulary, that diagnosis is added to the transaction and then any of the following may occur, depending on how your administrator has configured your user profile: you may be warned that secondary diagnosis is appropriate, you may be prompted to select a secondary diagnosis, or the secondary diagnosis may be* automatically added* to the charge transaction or clinical note. Keep in mind that you can always manually add or remove secondary diagnoses, regardless of how your user profile is configured. To do so, follow these steps:

• Select a diagnoses from the Favorites, Existing, or Department list, or by Searching for it. If it is a primary diagnosis that should be accompanied by one or more secondary diagnoses, then one of the following workflows occurs, based on how your user profile is configured:
  • While still on the Add Diagnosis screen, the following message is displayed immediately below the primary diagnosis code that you selected: “Additional Secondary Diagnoses - Tap to Edit.” You can do nothing, or you can tap on the red message to add a secondary diagnosis. When the Secondary DXs screen opens, select one or more of the preferred secondary diagnoses listed on this screen, and then tap OK. Note that this same message also shows on the main Charge Transaction screen, affording you another opportunity to select or unselect secondary diagnoses for this code.
  • While still on the Add Diagnosis screen, the Secondary DXs screen opens automatically and displays the preferred secondary diagnoses. Select one or more of the diagnoses from this screen, or select none, and then tap OK.
  • The preferred secondary diagnoses are automatically added to the charge transaction or clinical note without any user intervention. No warning message is displayed, since all appropriate secondary codes have been added. When you return to the main Charge Transaction screen or NoteWriter screen, you can review them and delete any of the secondary diagnoses that are not appropriate for the patient by tapping the Delete button next to that diagnosis. If you selected a secondary code in any of the workflows above (or if they were selected automatically), they are now listed on the main Charge Transaction screen or NoteWriter screen.