New Century Wellness

diagram for New Century’s information systemChapter 5Description:New Century Wellness Group offers a holistic approach to healthcare with an emphasis on preventivemedicine as well as traditional medical care. In your role as an IT consultant, you will helpNew Century develop a new information system.  Capstone Case:  New Century Health Clinic                               c BackgroundYou began the systems analysis phase by conducting interviews, reviewing existing reports, and observing office operations. (Your instructor may provide you with a sample set of interview summaries.) The New Century medical team performs services and medical procedures, which are coded according to the American Medical Association’s Current Procedure Terminology (CPT). CPT codes consist of five numeric digits and a two-digit suffix, and most insurance payers require the codes to be included with billing information.The new system must be able to handle the new ICD-10 procedure coding system, which will be required by the Centers for Medicare & Medicaid Services (CMS) beginning October 1, 2014. ICD-10 codes consist of seven alphanumeric characters, which can be electronically transmitted and received. New Century’s information system must interface with 25 California health insurance providers. The new system represents an opportunity for significant cost saving for New Century, and more convenience for patients, who will be able to go online to update medical information, schedule appointments, and request medical records.During your fact-finding, you learned that the clinic requires various reports, as follows:Daily appointment list for each provider. The list shows all scheduled appointment times, patient names, and services to be performed, including the procedure code and description.Daily report call list, which shows the patients who are to be reminded of their next day’s appointments. The call list includes the patient name, telephone number, appointment time, and provider name.Weekly provider report that lists each of the providers and the weekly charges generated, plus a month-to-date (MTD) and a year-to-date (YTD) summary as well as profit distribution data for the partners.Monthly patient statement, which includes the statement date, head of household name and address, previous month’s balance, total household charges MTD, total payments MTD, and the current balance. The bottom section of the statement shows activity for the month in date order. For each service performed, a line shows the patient’s name, the service date, the procedure code and description, and the charge. The statement also shows the date and amount of all payments and insurance claims. When an insurance payment is received, the source and amount are noted on the form. If the claim is denied or only partially paid, a code is used to explain the reason. A running balance appears at the far right of each activity line.Weekly Insurance Company Report.Monthly Claim Status Summary.In addition to these reports, the office staff would like automated e-mail and text messaging capability for sending reminders to patients when it is time to schedule an appointment. Data also needs to be maintained on employers who participate in employee wellness programs. This information can be used for marketing purposes throughout the year. Finally, the new system needs to track employee schedules, attendance, vacation time, and paid time off.Now you are ready to organize the facts and prepare a system requirements document that represents a logical model of the proposed system. Your tools will include DFDs, a data dictionary, and process descriptions.Tasks1. Prepare a context diagram for New Century’s information system.2. Prepare a diagram 0 DFD for New Century. Be sure to show numbered processes for handlingappointment processing, payment and insurance processing, report processing, and recordsmaintenance. Also, prepare lower-level DFDs for each numbered process.3. Prepare a list of data stores and data flows needed for the system. Under each data store, listthe data elements required.4. Prepare a data dictionary entry and process description for one of the system’s functionalprimitives. Solution : TasksPrepare a context diagram for New Century’s information system.Students who are interested in health information management or learning more about EDI systems and ICD-10 may find it helpful to review the Centers for Medicare & Medicaid Services information at the following Web site:http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/A sample diagram might look like this:  Context diagram for New Century Health Clinic Office System Prepare a diagram 0 DFD for New Century. Be sure to show numbered processes for handling appointment processing, payment and insurance processing, report processing, and records maintenance. Also, prepare lower-level DFDs for each numbered process.Sample DFDs follow: Diagram 0 DFD The four main processes shown on diagram 0 DFD are PROCESS APPOINTMENT (Process 1), PROCESS PAYMENT (Process 2), PRODUCE REPORTS (Process 3), and MAINTAIN RECORDS (Process 4). Samples of lower-level diagrams for these four processes follow: Diagram 1 DFD Diagram 2 DFD Diagram 3 DFD Diagram 3.1 DFDDiagram 3.2 DFDDiagram 4 DFDPrepare a list of data stores and data flows needed for the system. Under each data store, list the data elements required.The data flows are as follows:APPOINTMENT DATAAPPOINTMENT LISTAPPOINTMENT REQUESTAPPT DATACALL LISTCALL LIST DATACHARGESCLAIMCLAIM STATUS SUMMARYCPT CODESCPT FEE SCHEDULEFEE AND SERVICE DATAFEE DATAHOUSEHOLD CHANGEHOUSEHOLD DATAHOUSEHOLD UPDATEINSURANCE CARRIER DATAINSURANCE CHANGEINSURANCE CLAIM DATAINSURANCE COMPANY REPORTINSURANCE PAYMENTINSURANCE UPDATEMAILING LABEL DATAMAILING LABELSMTD PAYMENTSOFFICE STAFF REPORTS AND OUTPUTSPATIENT CHANGEPATIENT DATAPATIENT INPUTSPATIENT PAYMENTPATIENT REPORTS AND OUTPUTSPATIENT UPDATEPROVIDER APPOINTMENT DATAPROVIDER CHANGEPROVIDER CHARGESPROVIDER DATAPROVIDER INPUTSPROVIDER REPORTPROVIDER REPORT DATAPROVIDER REPORTS AND OUTPUTSPROVIDER UPDATEREMINDER POSTCARDREMINDER POSTCARD DATASCHEDULED APPT DATASCHEDULED SERVICE DATASERVICE CHARGESERVICE DATASTATEMENTSTATEMENT DATAYTD PAYMENTSThe data stores are as follows:COMPLETED APPT DATACOMPLETED SERVICE DATACPT FEE SCHEDULEHOUSEHOLDSINSURANCE CARRIERSMTD CHARGESMTD PAYMENTSPATIENTSPENDING INSURANCE CLAIMSPROVIDERSSCHEDULED APPOINTMENT DATASCHEDULED SERVICE DATA The data elements for each data store are as follows:COMPLETED APPT DATA (D27)Data elements:APPOINTMENT NUMBERAPPOINTMENT DATESTART TIMEEND TIMEPATIENT NUMBERPROVIDER NUMBER COMPLETED SERVICE DATA (D28)Data elements:APPOINTMENT NUMBERCPT CODEFEE CPT FEE SCHEDULE (D18)Data elements:CPT CODECPT FEEPROCEDURE NAME HOUSEHOLDS (D5)Data elements:HOUSEHOLD NUMBERHOUSEHOLD FIRST NAMEHOUSEHOLD LAST NAMEHOUSEHOLD ADDRESSHOUSEHOLD CITYHOUSEHOLD STATEHOUSEHOLD HOME PHONEHOUSEHOLD WORK PHONEINSURANCE CO. NUMBEREMPLOYER GROUP NUMBERYTD HOUSEHOLD CHARGESYTD HOUSEHOLD PAYMENTSYTD INSURANCE PAYMENTSPRIOR BALANCE INSURANCE CARRIERS (D8)Data elements:INSURANCE CO. NUMBERINSURANCE CO. NAMEINSURANCE ADDRESS 1INSURANCE ADDRESS 2INSURANCE CITYINSURANCE STATEINSURANCE ZIPINSURANCE PHONE MTD CHARGES (D7)Data elements:HOUSEHOLD NUMBERAPPOINTMENT NUMBERCPT CODEPROVIDER NUMBERFEE MTD PAYMENTS (D4)Data elements:HOUSEHOLD NUMBERPAYMENT DATEPAYMENT AMOUNTPAYMENT SOURCEINSURANCE CO. NUMBER PATIENTS (D2)Data elements:PATIENT NUMBERPATIENT LAST NAMEPATIENT FIRST NAMEBIRTHDATEHOUSEHOLD NUMBERRELATIONSHIP CODELAST EXAM PENDING INSURANCE CLAIMS (D22)Data elements:INSURANCE CO. NUMBEREMPLOYER GROUP NUMBERAPPOINTMENT NUMBERCLAIM AMOUNTPAYMENT AMOUNTPAYMENT DATEINSURANCE CHARGES MTDINSURANCE CHARGES YTDINSURANCE PAYMENTS MTDINSURANCE PAYMENTS YTDINSURANCE BALANCE OUTSTANDING PROVIDERS (D3)Data elements:PROVIDER NUMBERPROVIDER NAMECHARGES MTDCHARGES YTD SCHEDULED APPT DATA (D25)Data elements:APPOINTMENT NUMBERAPPOINTMENT DATESTART TIMEEND TIMEPATIENT NUMBERPROVIDER NUMBER SCHEDULED SERVICE DATA (D26)Data elements:APPOINTMENT NUMBERCPT CODEFEEPrepare a data dictionary entry and process description for one of the system’s functional primitives.Answers will vary, because students will be using the data flow diagrams they created in responding to previous questions. This assignment can be approached in several ways. Have students use structured English, decision tables, or another documentation technique. Although the New Century processes do not require a complex logical solution, create an additional New Century guideline, or policy, that would require the use of a decision table or decision tree. For example, New Century might decide to send out special reminders for patients in certain age groups or for those who have had certain procedures performed during the past year. The main objective is to provide an opportunity to practice and apply the skills learned in this chapter. Many sample documents have been prepared for several of the functional primitives shown in the DFDs on our data flow diagrams. Use these as examples, and encourage students to develop their own solutions. In addition, a full list of the functional primitives, including input and output data flows, have been provided. SAMPLE DOCUMENTATION FOR PROCESSES 1.1, 1.2, 1.3, AND 1.4: PROCESS 1.1: MAKE APPOINTMENT PURPOSE: Schedules a patient’s appointment and services.  INPUT DATA FLOWS: APPOINTMENT REQUEST PATIENT DATA CPT FEE SCHEDULE  OUTPUT DATA FLOWS: SERVICE DATA APPT DATA  PROCESS DESCRIPTION: For each APPOINTMENT REQUEST from PATIENT Retrieve PATIENT NUMBER from PATIENTS Verify PATIENT NUMBER For each CPT CODE in APPOINTMENT REQUEST Retrieve CPT CODE from CPT FEE SCHEDULE Add/Change/Delete CPT CODE in SCHEDULED SERVICE DATA Add/Change/Delete PROVIDER NUMBER in SCHEDULED SERVICE DATA Add/Change/Delete APPOINTMENT NUMBER, APPOINTMENT DATE, START TIME, PATIENT NUMBER in SCHEDULED APPOINTMENT DATA PROCESS 1.2: COMPLETE APPOINTMENT PURPOSE: Processes an appointment that has been completed  INPUT DATA FLOWS: EMPLOYER DATA PROVIDER DATA HOUSEHOLD DATA SERVICE DATA APPT DATA  OUTPUT DATA FLOWS: CLAIM CHARGES PROVIDER CHARGES SERVICE CHARGE SERVICE DATA APPT DATA  PROCESS DESCRIPTION: For each APPOINTMENT NUMBER Retrieve HOUSEHOLD NUMBER from PATIENTS Retrieve EMPLOYER GROUP NUMBER from HOUSEHOLDS Retrieve INS. CO. NUMBER from HOUSEHOLDS For each APPOINTMENT NUMBER in COMPLETED APPOINTMENT DATA Retrieve FEE from SERVICE DATA Apply CHARGE to HOUSEHOLDS Apply PROVIDER CHARGES to PROVIDERS Apply LAST EXAM to PATIENTS Apply FEE to MTD CHARGES Add APPOINTMENT NUMBER, APPOINTMENT DATE, START TIME, END TIME, PATIENT NUMBER in COMPLETED APPOINTMENT DATA Add CPT CODE, PROVIDER NUMBER, FEE in COMPLETED SERVICE DATA Delete APPOINTMENT NUMBER, APPOINTMENT DATE, START TIME, END TIME, PATIENT NUMBER in COMPLETED APPOINTMENT DATA Delete CPT CODE, PROVIDER NUMBER in SCHEDULED SERVICE DATA Send CLAIM to INSURANCE COMPANY PROCESS 1.3: MODIFY CPT CODE PURPOSE: Add/Change/Delete an American Medical Association CPT code  INPUT DATA FLOWS: CPT CODES OUTPUT DATA FLOWS: CPT CODES PROCESS DESCRIPTION: For each CPT CODE CHANGE from AMERICAN MEDICAL ASSOCIATION Apply CPT CODE to CPT FEE SCHEDULE PROCESS 1.4: MODIFY CPT FEE PURPOSE: Add/Change/Delete a CPT fee  INPUT DATA FLOWS: FEE DATA OUTPUT DATA FLOWS: FEE DATA PROCESS DESCRIPTION: For each FEE CHANGE from PROVIDER Apply FEE to CPT FEE SCHEDULE OTHER FUNCTIONAL PRIMITIVE PROCESSES: PROCESS 2.1: PROCESS PATIENT PAYMENT PURPOSE: Process a payment received from a patient INPUT DATA FLOWS: PATIENT PAYMENT OUTPUT DATA FLOWS: MTD PAYMENTS YTD PAYMENTS PROCESS 2.2: PROCESS INSURANCE PAYMENT PURPOSE: Process a payment received from an insurance company  INPUT DATA FLOWS: INSURANCE PAYMENT OUTPUT DATA FLOWS: MTD PAYMENTS YTD PAYMENTS PROCESS 3.1.1: CREATE CALL LIST PURPOSE: Prepare and print the daily call list that shows all patients who are to be called to be reminded of their appointment  INPUT DATA FLOWS: CALL LIST DATA OUTPUT DATA FLOWS: CALL LIST PROCESS 3.1.2: CREATE APPOINTMENT LIST PURPOSE: Prepare and print the daily appointment list that shows all patients and their scheduled services for each provider  INPUT DATA FLOWS: SERVICE DATA PROVIDER APPOINTMENT DATA OUTPUT DATA FLOWS: APPOINTMENT LIST  PROCESS 3.2.1: CREATE PROVIDER REPORT PURPOSE: Prepare and print the weekly provider report that summarizes each provider’s charges for the week  INPUT DATA FLOWS: MTD PAYMENTS PROVIDER REPORT DATA SERVICE CHARGE OUTPUT DATA FLOWS: CLAIM STATUS SUMMARY INSURANCE COMPANY REPORT PROVIDER REPORT PROCESS 3.2.2: CREATE REMINDER POSTCARDS PURPOSE: Prepare and print reminder postcards for each appointment  INPUT DATA FLOWS: REMINDER POSTCARD DATA OUTPUT DATA FLOWS: REMINDER POSTCARD PROCESS 3.2.3: CREATE MAILING LABELS PURPOSE: Prepare and print patient mailing labels  INPUT DATA FLOWS: MAILING LABEL DATA  OUTPUT DATA FLOWS: MAILING LABELS PROCESS 3.2.4: CREATE STATEMENT PURPOSE: Prepare and print monthly statements to patients  INPUT DATA FLOWS: STATEMENT DATA OUTPUT DATA FLOWS: STATEMENT PROCESS 4.1: MODIFY PATIENT PURPOSE: Add, change, and delete patient and household data received from patients  INPUT DATA FLOWS: PATIENT CHANGE OUTPUT DATA FLOWS: PATIENT UPDATE PROCESS 4.2: MODIFY HOUSEHOLD PURPOSE: Add, change, and delete household data changes received from patients  INPUT DATA FLOWS: HOUSEHOLD CHANGE OUTPUT DATA FLOWS: HOUSEHOLD UPDATE PROCESS 4.3: MODIFY INSURANCE CARRIERS PURPOSE: Add, change, and delete insurance carrier data received from patients  INPUT DATA FLOWS: EMPLOYER CHANGE OUTPUT DATA FLOWS: EMPLOYER UPDATE PROCESS 4.4: MODIFY PROVIDER PURPOSE: Add, change, and delete provider data  INPUT DATA FLOWS: PROVIDER CHANGE OUTPUT DATA FLOWS: PROVIDER UPDATE

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