Topics Evaluation & Management Search:  
The billing amount for every encounter depends on the Level of Service provided by the Doctor. There are pre-defined standards and parameters to qualify for a level of service.

The forms pre build in the application are:
  1. Office Visit
  2. New Patient
  3. Out Patient Consultation
  4. Inpatient Consultation
  5. Hospital Inpatient Service
  6. Hospital Care
  7. Confirmatory Consultations
  8. Follow Up Consults
  9. Emergency Visits
More can be added if required by the Support team.

When the Clinic Encounter Types are defined, user also assigns the E&M form applicable in Settings > Configuration > Clinic > Enc Type.

The E&M form applicable to the current encounter is displayed on selecting this option. Form contents are fixed. User has an option to enter some fields on the last row.

The form fields are:

EMC: Evaluation and Management Code. This is one of the applicable CPT Codes. The description of the CPT code is displayed on the tool tip.

Hist: History of the Patient.

HPI: Elements reviewed in History of Present Illness.
Please note that:
  • One encounter has multiple complaints.
  • One complaint corresponds to one template.
  • One template has multiple elements.
ROS: Systems and Elements reviewed in Review of Systems.

PFSH: Past, Family, Social History. Shows three flags:
  • P if Past Medical History was reviewed.
  • F if Family History was reviewed.
  • S if Social History was reviewed.
MDM: Medical Decision Making.

NDMO: Number of Diagnosis Or Medical Options. By default Minimal. User can select appropriate if required.

ACDR: Amount and / or Complexity of Data to be Reviewed. By default Minimal to None. User can select appropriate if required.

RCMM: Risk of Complication and or Morbidity or Mortality. By default Minimal. User can select appropriate if required.

TF: TF stands for Time Factor. This is the percentage of face-to-face time spent in consulting / counseling the Patient. By default Zero.

User can click on a Radio Button to select a Level of Service. User may also click on the buttons under Time Factor column. Note that if the Doctor has spend a significant time in consulting the patient without any ROS/HPI even then he is entitled to charge a higher level of service.
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