Background

The UWG medical team performs services and medical procedures, which are coded according to the American Medical Associations (AMA) 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.

UWGs information system must interface with 25 California health insurance providers. The

new system represents an opportunity for significant cost saving for UWG, 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, (Remember to refer back to the interview summary provided) 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 days 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 a profit distribution data for the partners.

Monthly patient statement, which includes the statement date, head of household name and address, previous months 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 patients 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.

Tasks

1. Prepare a context diagram for UWGs information system. Your context diagram should include the following Entities: Patient, Insurance Company, American Medical Association, Office Staff and Provider.

2. Prepare a diagram 0DFD for UWG. Be sure to show numbered processes for handling appointment processing, payment and insurance processing, report processing, and records maintenance.