Topics Evaluation & Management Search:  
E&M coding is a process by which patient encounters are translated into CPT codes to facilitate billing. There are different E and
M codes for different types of encounters. The billing amount for every encounter depends on the level of service provided by the doctor. There are predefined standards and parameters to qualify for a level of service. The user has the option to click on an option to select a level of service. Alternatively, the buttons under the Time Factor column are clickable, and the user can add the additional time duration as required. Note that if the doctor has spent a significant amount of time consulting the patient without any ROS/HPI, even then they are entitled to charge a higher level of service.

The forms pre-built 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, the 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. The form contents are fixed. The 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 tooltip.
  • For EMC code 99205 or services longer than 75 minutes, the prolonged code 99417 is available for every additional 15 minutes spent after 75 minutes.
  • For EMC code 99215 or services longer than 55 minutes, the prolonged code 99417 is available for every 15 minutes spent after 55 minutes.
    • Select the 99205 and 99215 EMC codes to display the Prolonged Services table below the "Select Complexity (MDM)" table. Select the Additional Minutes from the Additional Minutes Spent drop-down menu list. The default option selected in the list box will be the first option, which is blank.
  • The code 99201 is not available for selection.
Hist: History of the patient.

HPI: Elements reviewed in the 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 the Review of Systems.

Physical: The physical bullets are counted from physical tests. Also, as per "1997 CMS E/M guidelines", three vital tests should be counted as one physical bullet in E&M.  For example, if three vital tests are answered, then they are counted as one physical bullet on the E&M screen.

PFSH: Past, Family, and Social History. It shows three flags:
  • P if the Past Medical History was reviewed.
  • F if the Family History was reviewed.
  • S if the Social History was reviewed.
MDM: The MDM column displays the level of complexity based on the selected EMC. Click on the hyperlink to open the Level of MDM popup. The popup invoked by clicking the hyperlinks consists of two cards. On the first card, there are four columns:
  • Level of MDM
  • Number and Complexity of Problems Addressed
  • Amount and Complexity of Data to be Analyzed
  • Risks of Complications.


    • The second card is the Additional Comments free-text box area wherein you can add the additional notes related to the encounter.     On the Level of MDM popup, by default, the Level of MDM radio button is selected for the selected MDM. Select the required elements from the Level of MDM popup to add the encounter-related details under the Assessment screen.

    TF:     TF stands for Time Factor. This is the number of minutes of face-to-face time spent consulting or counseling the patient. Click this button to invoke the time duration popup, where the user can enter the Activity Summary under the Activity Summary text box field.

    Calculate MDM Calculate MDM icon: Upon clicking the Calculate MDM button, the Calculate MDM popup displays. The Calculate MDM popup consists of Criteria A, B, and C, their relevant scores and statuses, and the calculated MDM. The display of the Calculate MDM icon is dependent on the property, enm.mdm.hpi.problem.test Only if there is a value assigned to the property does the icon display on the E&M screen.

    Note iconNote: The calculated MDM section, available at the bottom of the E&M screen, is displayed in disabled mode for a New Patient (99202-99205) and an Established Patient (99211 and 99215).

    Criteria A:

    HPI
    If the property, enm.mdm.hpi.problem.test, consists of an HPI complaint test code to be considered for Criteria A, then the test code mentioned in the property should have its result type set to 'score'. If the same HPI complaint test code (as mentioned in the property) is included in multiple templates and answered multiple times, then the sum of the scores is displayed in the output of Criteria A. The status for Criteria A is based on the total score of the HPI complaint. Refer to Table 1.
    Table 1: Legends
    No.  Score Status
    1. <= 2 Low
    2. = 3 Moderate
    3. = 4 High

    If an HPI test with a result type of 'Score' and having the following options is answered multiple times in an encounter, then the score for the option value "New - no addtl workup" is counted only once, irrespective of the number of times the test has been answered with this option selected.
    • Est - stable/improved
    • Est – worsening
    • New - no addtl workup
    • New - addtl workup planned
    Criteria B:

    I. Lab Order/Review
    If the property, enm.mdm.labreview.testcodes consists of the Lab Order/Review's test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Lab Order/Review criteria's count increases by one.  Even if the test (of the respective test code) is not answered and the lab is ordered/reviewed, the Lab Order/Review criteria's score increases by one.

    II. Radiology Order/Review
    If the property, enm.mdm.radreview.testcodes, consists of the Radiology Order/Review's test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Radiology Order/Review criteria's count increases by one. Even if the test (of the respective test code) is not answered and the radiology is ordered/reviewed, the Radiology Order/Review criteria's score increases by one.

    III. Review and Summarize of Old Records
    If the property, enm.mdm.reviewoldrecord.testcodes, consists of the test code and that respective test code was used in any template(s) or the test(s) have been answered in the old reviewed records, then the Review and Summarize of Old Records criteria count increases by two.

    IV. Ordered Old Records
    If the property, enm.mdm.orderoldrecord.testcodes consists of the test code and that respective test code was used in any template(s) or the test(s) have been answered in the old ordered records, then the Ordered Old Records criteria count increases by one.

    V. Specialty
    If the property, enm.mdm.specialty.templates consists of the template name and that respective template is used or answered in the encounter, then the Specialty criteria count increases by one.

    VI. Discussed Consult with Provider
    If the property, enm.mdm.consult.testcodes consists of the test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Discussed Consult with Provider criteria's count increases by one.

    VII. Reviewed PMP
    If the property, enm.mdm.reviewpmp.testcodes consists of the test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Reviewed PMP criteria's count increases by one.

    VIII. Order Consult
    If the property, enm.mdm.orderconsult.testcodes consists of the test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Order Consult criteria's count increases by one.

    IX. Order Test
    If the property, enm.mdm.ordertest.testcodes consists of the test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Order Test criteria's count increases by one.

    X. Order Procedure
    If the property, enm.mdm.orderprocedure.testcodes consists of the test code and that respective test code is used in any template(s) or the test(s) have been answered, then the Order Procedure criteria's count increases by one.

    XI. Order DME
    If the property, enm.mdm.orderdme.template consists of the template name and that respective template is used or answered in the encounter, then the Order DME (Durable Medical Equipment) criteria count increases by one.

    The status for Criteria B is based on the total score of Lab Order/Review, Radiology Order/Review, Review and Summarize Old Records, Ordered Old Records, Specialty, Discussed Consult with Provider, Reviewed PMP, Order Consult, Order Test, Order Procedure, and Order DME. Refer to Table 2.
    Table 2: Legends
    No.  Score Status
    1. <= 2 Low
    2. = 3 Moderate
    3. >= 4 High

    Criteria C:

    Drugs Prescribed
    If the property, enm.mdm.rx.template consists of the template name and that respective template is used or answered in the encounter, then the Prescription criteria is set to 'Yes' and the status is set to 'Moderate'. However, if the template is not used in the encounter, then the Prescription criteria is set to 'No' and the status is set to 'Low'. Please note that this criterion is not only dependent on the template set in the property; the score of the Prescription criteria is set to 'Yes' even if any drug is prescribed in the current encounter.

    Calculated MDM:

    The calculated MDM complexity level based on the highest of Criteria A, B, and C is displayed. When the user clicks the OK button, the appropriate calculated MDM complexity level is displayed on the E&M screen.
    For example: if Criteria A is Low, B is Moderate, and C is Moderate, then the Calculated MDM will be Moderate.

    Note iconNote:

    • Additionally, the user has the option to change the computed MDM complexity level manually from the E&M screen. The MDM calculated by the application and the values selected manually are saved in the database. Also, a tabular report can be generated for these values.
    • If the previous encounter consists of the tests that were defined to calculate MDM (Medical Decision Making) and are answered, then the MDM that was calculated upon clicking the Calculate MDM button will be available and auto-calculated in the next encounter's Calculate MDM popup without the user needing to click the Calculate MDM button. This is available only if the user has explicitly copied (using the Copy button on the Test Exec screens) the answered tests which are defined in the Calculate MDM property from the previous encounter to the next encounter.
    Suggested Code:

    As the user selects the complexity of Medical Decision Making from the drop-down list, an alert is displayed with the appropriate Suggested Code (EMC) for that Medical Decision Making. An alert with the Suggested Code is also displayed when the complexity of MDM is calculated using the Calculate MDM button.

    Action buttons on Calculate MDM popup

    OK: Click the button to automatically select the complexity of the calculated MDM on the E&M screen and close the Calculate MDM popup.

    Cancel: Click the button to close the Calculate MDM popup.

    Action buttons on E&M screen

    Save: Click the Save button to save the E&M details.

    Reset: Click the Reset button to revert to the last saved details.

    Close: Click the Close button to close the E&M screen and navigate back to the Face Sheet screen.