Description

The Issue AP Report pop-up allows you to issue an anatomic pathology report. It contains the information needed to confirm that all necessary results, billing codes, ICD-10 codes and signatures are present to ensure maximum reimbursement. 

Access

TaskCenter > Manage Testing > Work in Progress > double-click an AP entry to open AP Worksheet > Review and Issue button


Technical Manual

Billing Codes

CodeThis column is populated by the CPT or charge code.
Item

This column is the item that added the code to the case.

  • Format for Specimen Source level codes: <Part ID Suffix><period><space><Source Name><space><Procedure>
    • Example: A. Skin biopsy
  • Format for Test level codes on Case-associated Tests: <Test Name>
  • Format for Test level codes on Part-associated Tests: <Part ID Suffix><period><space><Test Name>
    • Example: A. Special AP Part Test
  • Format for Test level codes on Block-associated Tests: <Part ID Suffix><Block ID delimiter><Block ID Suffix><period><space><Test Name>
    • Example: A-1. Cell Block Test
  • Format for Test level codes on Slide-associated Tests: <Part ID Suffix><Block ID delimiter><Block ID Suffix><Slide ID Delimiter><Slide ID Suffix><period><space><Test Name>
    • Example: A-1-5. Alcian Blue Stain
Add Billing

Select this button to open the Add Bill-only Item pop-up. 

  • Bill-only Item Search: Use this field to search for and select Anatomic Pathology bill-only items.
  • Level: This column allows you to pick if the code should be considered at the case level or one of the parts on a case.
  • Name: This column displays the "Name" value from the Bill-only Items table.
  • Code: This column displays the code value.
  • Description: This column displays the code description.
  • Remove: This column contains an X you can select to delete the item from the table.

Orchard Software recommends all CPT codes for Anatomic Pathology be set up as bill-only items. Adding bill-only items to a case is the only manner in which new CPT codes may be applied to the order, even if a CPT code is removed from the order by accident.

To add bill-only items to the case, they must first be created on the Bill-only Items administration page. See Bill-only Items.

AP cases can have multiple codes assigned to one bill-only item.

RemoveSelect the X to delete the billing item from the report.


After Billing Rules

After Billing Rules AreaUse this area to see how rules will affect the billing codes and what will be printed on AP Reports and delivered to external billing systems.
RefreshSelect this button to rerun the rules and update the area.


ICD-10 Codes

ICD-10 Codes Area

Use this area to see the list of ICD-10 codes. 

The codes are listed in bold font and are formatted with <code><space><hyphen><space><code description>. 

Edit ICD-10s

Select this button to open the Edit ICD-10 Codes pop-up.

  • ICD-10 Code Search: Use this field to search the ICD-10 Codes table for code and description.
  • Sort: Use this column to select and drag to sort the order of the codes.
  • Remove: Use this column to select the X to remove the item from the table.


Signatures to be Reported

Performing LocationSelect in or begin typing in this search-as-you-type field to search for and select the location where the pathologist read the slide(s) for the case. The location you select here will be tied to the added signature as its performing location. This is automatically populated to the user's signed-in location by default; however, you can change it if needed.
Action text

Use this drop-down list to choose one of the following action options:

  • Electronically signed by
  • Signed by
  • Reviewed by
  • Screened by
  • Rescreened by

You can set your default signature action text on the Users page so that the system will automatically select the text in the drop-down list that matches your role.

Signing UserUse this drop-down list to select from a list of users who you have permissions to sign AP reports for.
Add SignatureSelect this button to add a row to the table based on options selected in the Action text and Signing User drop-down lists.
Table 

Use the Signatures to be reported table to view signatures for the AP report. The table has the following columns:

  • Signed Date/time: This column displays the date/time the signature was added to this case.
  • Signature Text: This column combines the Action text and Signing User to display the signature text for the report.
  • Added by: This column displays the user who selected the Add Signature button.
  • Performing Location: This column displays the location where the pathologist read the slide(s) for the case. This location is tied to the added signature on the report.
  • Primary: This column indicates which signature should be treated as the "Principal Result Interpreter" in OBR-32
  • Remove: Use this column to remove the signature record from the current case.

You can configure certain users to have their signature automatically appear in this table after selecting the Review and Issue button on the AP Worksheet pop-up.

If the case already has a primary signature from another user, and no signature for the current user, the system will prompt the current user if they would like to add their signature as a secondary signature.

For AP cytology order choices, the signature of the user with the highest AP cytology role will be assigned primary status. For example, if a primary screener initially signs the report and then a pathologist later signs it, the pathologist's signature automatically becomes the primary signature on the case when their signature is automatically added. The primary screener role is the lowest role, the QC screener is the middle role, and the pathologist is the highest role. 


Previous Report Signatures

This table lists signatures that have been previously included on issued reports. 

Reported Date/TimeUse this column to view the date and time of the report that the signature was included on.
Report TypeUse this column to view the report type that the signature was included on.
Signature TextUse this column to view the signature text included on the report.
Added ByUse this column to view the user that added the signature.
PrintUse this toggle button to print the signature on the next report. Set the button to on to print the signature on the next report. Set the button to off to leave the signature off the next report.


Report Preview Area

This area displays a preview of the report. If the order has image tests that the system is configured to automatically annotate, those report image tests will display with annotations in this area. 

Report Type

Use this drop-down list to select the type of AP report to be issued for the case.

Prior to initial approval (issuing a final-level report), the options include:

  • Final: This option is the default.
  • Preliminary

After a Final report has been issued and a request that the case be reopened, the drop-down list options include:

  • Addendum
  • Amended

If the case is currently in an amendment state, only Amendment report types will display. If the case is currently in an addendum state, only Addendum report types will display.


Buttons

HelpSelect the question mark button located in the top-right corner to open the help files.
ExpandSelect the expand button located in the top-right corner to make the Issue AP Report pop-up full screen.
Request Rescreen

This button is only available for users who are Primary Screeners in anatomic pathology GYN cytology cases and when the Allow Primary Screener to send this case to be rescreened setting is enabled in AdminCenter > Order Choice Setup > Order Choices > Order Choice AP Setup > AP GYN Cytology Settings.

Select the button to manually request that a case be rescreened. A confirmation pop-up will appear.

Complete Case: Select the button to complete the case and close the Issue AP Report pop-up.

Issue Report

Select this button (or press Alt+I) to apply any changes and issue the report.

If the Report Type is Final, Addendum, or Amended, selecting this button will open the Issue Report Confirmation pop-up. Select Issue Report on the confirmation pop-up to proceed with issuing the report.

The AP Worksheet will be placed in a closed state after issuing a Final report. When in the closed state, you cannot edit reported results, parts, or remove blocks/slides.

Issue Report Warning: If there are linked order choices on the order that are not yet approved, you cannot sign out the case unless you have the appropriate permissions. An alert will appear displaying the test names (and their workflow status) that must be approved. If you have the appropriate permissions set up, you can select the Override and Approve button to issue the report before the other linked order choices are approved. This warning does not appear for preliminary reports.

Issue Report and Close

Select this button to apply any changes and issue the report. The AP Worksheet closes, and you'll return to the Work in Progress page.

The AP Worksheet will be placed in a closed state after issuing a Final report. When in the closed state, you cannot edit reported results, parts, or remove blocks/slides.

Issue Report Warning: If there are linked or reflexed order choices on the order that are not yet approved, you cannot sign out the case unless you have the appropriate permissions. An alert will appear displaying the test names (and their workflow status) that must be approved. If you have the appropriate permissions set up, you can select the Override and Approve button to issue the report before the other linked or reflexed order choices are approved. This warning does not appear for preliminary reports.

Save Signatures and CodingSelect this button to save the billing code, ICD-10 code, and signature changes without issuing the report.
CancelSelect this button to return to the AP Worksheet Pop-up. Any unsaved changes will be cancelled.