How do I create my signature block? 

Follow the attached go by. This is important because … coding. But really though, it’s super important. Please do!

 

How do I update old/copied forward allergies?

It won’t let me cancel them! To cancel an allergy, right click the allergy, click “cancel,” fill in the yellow required fields (yes, even though you’re trying to cancel the order) and then click “OK.”

 

How do I make sure my E&M coding is correct? 

As it turns out, after you sign an E&M code for your note, your staff can’t delete or modify it, meaning that it’s ideal if it’s done correctly the first time. We recommend talking with your staff when you’re staffing with them to determine what the E&M code should be and verifying that you are going to put in the correct GC/GE modifier.

 

How do I send a message to a patient? 

Use the in between encounters go by below. Sticking points that have come up is that to send the message to the patient you click “to consumer” and if you want to place orders, you have to create the in between encounter from OUTSIDE the patient’s chart (this is discussed in depth in the above mentioned go by, the faculty in RCC staffing rooms are also happy to help)

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What should I know about CPT Codes? 

As it turns out you can add two CPT modifiers to your E&M code (ie one for telehealth and your GC/GE modifier). To do this, select “93” (telehealth without video conferencing), hold down “Ctrl” on your keyboard, and scroll down to then also select “GC” or “GE”

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How do I complete an outpatient note? 

1. Enter order for E&M code (coding summaries in first and/or second attachment). Be sure to add the appropriate CPT modifier (GC or GE as appropriate). If the appointment was virtual, then you are supposed to use the 93 CPT modifier. At present Genesis only allows the use of a single CPT modifier. We were told that there are going to add a second CPT modifier drop down box soon so that residents can place the 93 and GE modifiers. For now we are using GE only for resident virtuals. The second attachment is a one-page up to date E&M coding reference. The third attachment is the latest full coding briefing we received at BAMC. Good detailed coverage of coding issues for 2023.

2. Enter order for “Change attending to”. Make sure to put attending name in yellow field under order details.

3. When your are ready to close your note, click Sign/Submit. Title the note appropriately: WR IM X (X = A, B, C… corresponding to your PCMH team) – xxx (xxx = Annual, Pre-op, or Primary Reason for Visit). For example, WR IM A – Follow-up diabetes or Walter Reed IM E – Cough. Add the supervising staff’s name in the “provider field” and select the Sign radio button (not review/cc) and click sign at the bottom to send the note to the staff to review and sign.

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How should I title my note? 

“WR IM [clinic name] [Virt] – [reason for clinic visit]”

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Can I pre-chart on my patients? 

Yes as long as you’re within 10 days of the visit. Information updated in problems and meds will be carried over even if the appointment gets cancelled (although S/O and A/P information appear to get lost)

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How do I do in between encounters (ie T cons)? 

Use the below go by. If the patient has never been seen in Genesis, you’ll need the clinic to register the patient in Genesis before you can do this.

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What do I need to know about E&M Codes?

• See below “2023 Outpatient E&M Leveling Tool” document for instructions on which E&M codes to pick. This is very similar to the prior AMA coding grid.

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What should my patient leave the appointment with?

• Consider creating a Patient Summary to give to pt at the end of encounter

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How do I chart prev med information? 

If doing an annual physical, remember to add the prev med E&M code with your GC/GE modifier under this code. “25” will be the CPT code under your other E&M code (99211 – 99215). Three options for charting the information itself are:

• Recommendations tab: the Cerner/institutional preferred option

• A dot phrase in the assessment and plan under a well adult coded problem: what most people do ß ***Tom Kane has created autotext for this, feel free to copy from him!

• A dot phrase in the “history of present illness (shared)” section of the Primary Care Workflow: the advantage of this over b. above is that other clinicians can see what you have documented when they are seeing a patient (as opposed to having to find your last note and copy and paste that data into their note)

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How do I put in outpatient referrals?

Order “Referral request 2.0” and specify the specialty under “Medical Service.” “Referral order type” should be “Evaluate and treat”. ROFR should always be “no.” (this means right of first refusal). For integrative health referrals, one of the below applies:

• For embedded psychology, med psych liaison clinic, obesity clinic, and diabetes classes/nutrition, place referral 2.0 order to “Internal Medicine” and specify in the comments your referral details and to which service you would like your patient appointed

• For all other embedded services, such as mind-body classes, patients should be self referring – they can call IRMAC and be booked directly.

 

How do I order meds?

• You still have to order them to the specific DoD pharmacy as we’ve done in the past (unfortunately. This is different from what we had been told pre-go live). You should be able to modify the pharmacy by clicking on the drop down menu next to “Send To:” in the top right corner of the lab order. If you don’t see the option you want on the first screen, select “Other.” You can find the specific pharmacy you’re looking for by looking at the attached Pharmacy location key. Make sure to delete the city and state that default if you aren’t getting the results you’re looking for.​

• If you’re getting an error that “the provider is missing an eprescribing relationship for the facility” or an error about your NPI number not being recorded, please call 301-295-4490

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Is there a way to make behavioral health notes sensitive? 

Yes – for type of note select “protected note – not in patient portal”

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How do I order a cardiology study? 

• Overview below!

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How do I order a mammogram? 

• Overview below!

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How do I create an in-between encounter? 

• Overview below!

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What do I do if I can't find my patient's surgery in the histories section?

• If you cannot find the surgery (procedure) that you’d like to enter into past medical history, select “document as free-text” option that is at the bottom of the choices

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What do I need to document for virtual health appointments?

• Remember to add the telemedicine disclaimer for virtual visits

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​​How do I order a Zio Patch? 

The process differs slightly based on whether the patient is Medicare eligible or not. For patients using Tricare, you’ll need to enter two referrals – “CV Extended Holter Monitor” and “Referral 2.0” for DME. For Medicare eligible patients, it’s just one referral to “CV Extended Holter Monitor.” The referral should include the DOD ID (Tricare) or Medicare benefits number and Medicare Part B number in a standardized sentence like this: “Patient is a ______ year old Male/Female being evaluated for ________, would like a ______ day Zio cardiac Monitor from IRhythm Phone: 1-888-693-2401 Fax: 1-888-693-2402. Benefits ID#______________”. You need to specify number of days – options are 3, 7, or 14 days. After placing the order, be sure to email DHA NSA Bethesda J-11 List Cardio-Amb Monitors at dha.bethesda.j-11.list.cardio-amb-monitors@health.mil to inform them about the order. For complete details (and the next time you order a Zio honestly it’s probably a good idea to pull these instructions up) see the attached word doc (“Outpatient_Zio Patch ordering”).​​

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How do I order insulin needles?

Order them as the pen needles and don’t specify a location (this should auto-default)

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How do I refer to Coumadin Clinic?

First – probably double check that the patient actually needs coumadin as opposed to a DOAC. Second – if they really do need coumadin, refer to the attached go by (“Outpatient_How to refer to Coumadin Clinic”)

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What do the green and red signs next to medications mean?

These are formularly indicators, but are not always accurate. Tricare formulary search is the best bet for now to figure out formulary status. This is an issue that’s being worked on at the enterprise level. You can search medications and find whether they are formulary or not by Googling “Tricare formulary search” and clicking on the express scripts link, or by going to this hyperlink: https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/

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Who should I contact for pharmacy related questions and what’s the best method?

Outpatient pharmacy prefers AMS connect – you can contact them through either of the two outpatient pharmacy groups depending on which pharmacy you’re trying to reach: OUTPATIENT AMERICA PHARMACY or OUTPATIENT ARROWHEAD PHARMACY

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I’m entering a medication where the quantity isn’t obvious and I’m not sure what to put to ensure my patient gets the number of days I want to prescribe. Help?

For medications where quantity is not obvious (e.g. injectable GLP1As, albuterol (or any other inhalers), Imitrex, etc) – if you do not know the quantity: in the dispense quantity put 1 (or 2, 3 etc) EACH (EA). ADD under INSTRUCTIONS TO THE PHARMACY (NOT order comments) (e.g. provide 90 day supply, or provide 3 inhalers, etc)

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How do I order a DEXA?

Please be aware of the specifics of ordering DEXAs at WRNMMC:

• Referral 2.0 to endo, Reason: DEXA. referral type: procedure (NOT eval/treat – if you do eval/treat the patient will likely be funneled into a clinic apptment which is even longer wait)

• Wait time is about 2 mos

• Hopefully results will come back thru “documents” in MHSG

• If patients want DEXA to be done at FBCH:

• These are done thru Nuclear Medicine at FBCH, You need to put in the referral to Nuc Med and request bone density

• The patient needs to call FBCH Nuc Med (although if they try to book thru IRMAC they would hopefully send them to nuc med at FBCH)

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How do I order allergy testing?

Order “Allergens, WHASC Allergy Screening”

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Is there a way to change problems so that they show up as something other than the ICD-10 code in my note?

Yes – click on the problem à click “Modify” --> type what you’d like the problem to appear as in your note in the “display as” field. To my knowledge though you can’t make all the comments show up in the note. You also can’t delete comments, so ideally only put information there that the patient will need their future providers to know indefinitely (ie not “last HA1c 8.5” since this will change, but “with diabetic retinopathy requiring YAG laser in 2020” would be helpful)

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How do I order TTEs?

Order CV trans-echo

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How do I order PFTs?

Do not use the PFT order, but rather use referral 2.0 to refer to pulm and then type “***PFT Request** as the indication.

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How do I refer to genetics?

Referral 2.0 --> medical genetics

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How do I make behavioral health notes confidential?

Make a protected note as the note type

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When patients get an outpatient EKG at cardiology where does that get uploaded?

Clinical images (in the blue column on the left)

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What do I do about virtual check in/check out shenanigans? (ie my patient who was virtual that I actually saw got marked as a no show the next day, or the virtual patient that I called but never picked up is now showing up as someone for whom I have delinquent documentation) 

Talk to your clinic teams about either getting another appointment made or getting the appointment cancelled. The workflow for this is being ironed out and is a bit of a sticky situation. If you’re having issues, feel free to email your team admins, in your respective clinics, Mr. Valverde, and cc the chiefs.

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How do I refer to wound care?

Refer to General Surgery and specify wound care.

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JLV through Genesis is giving me an error, how do I get around this?

You may need to talk to IT to get them to reset your JLV account, but you can also use the web link to get around this issue – jlv.health.mil/JLV/app/index

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What is the correct order for FIT testing?

Occult blood stool

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What is the correct order for an iron panel with ferritin?

Iron group. (see also “General_Laboratory CHCS-MHSG Cross-Walk” for more questions about labs we used to order and their new names, not everything is there but lots of things are)

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Is there a way to order immunizations in Genesis?

Essentially no – the orders in Genesis are reserved for allergy/immunology and are used for actually giving the vaccine. You can still use paper order forms, but if the patient is in the age range for a specific vaccine, all they should need to do is go to the imms clinic and say the need that vaccine.

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How do I order an MPS in Genesis?

Type NM for nuclear medicine and then it should come up

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How do I refer to OMFS as an outpatient?

Surgery, oral and maxillofacial