How to Perform E&M Coding

Summary

The Net Health Employee Health and Occupational Medicine Charting Templates and Wizards have been designed to assist clients in arriving at the most accurate Evaluation and Management (E/M) Services coding, for purposes of insurance reimbursement. Unfortunately, the rules for coding visits tend to change over time, and there are several versions and interpretations of the coding guidelines. It is possible that different payers, different types of payers, and different states may enforce their own interpretations of the rules for coding. For this reason, the Net Health Employee Health and Occupational Medicine EMR does not directly code visits, but provides coding feedback during the charting process, so that providers (or professional coders on staff) can determine the correct E/M code for each individual visit. It is the client's responsibility to ensure that the final coding is correct, regardless of the feedback that the Net Health Employee Health and Occupational Medicine EMR is able to provide.

Net Health Employee Health and Occupational Medicine does not automatically code visits. Rather, it provides physicians with information about the level of documentation in three areas which is needed for a particular level visit, the level of documentation achieved so far in each area, the level of visit which current documentation supports, and some details on how Net Health Employee Health and Occupational Medicine determined this level. This is not magic. How effectively Net Health Employee Health and Occupational Medicine makes E/M calculations is completely dependent upon how effectively the coding elements of Templates and Wizards have been set up. The coding elements of all new Templates and Wizards must be reviewed by an expert Since clinic reimbursement is dependent upon setup, the importance of this cannot be overstated.

Getting started? Net Health Employee Health and Occupational Medicine comes with a starter set of Templates and Wizards. Since the interpretation of the AMA coding guidelines varies by state, facility, purpose and payer, setup that accurately calculates E/M levels in one clinic will not necessarily do so in another. Therefore, the coding elements in those starter Templates and Wizards cannot be guaranteed to perform the way you need! If you are just starting with Net Health Employee Health and Occupational Medicine, it is vital that a coding expert review coding in all Templates and Wizards to confirm that they are consistent with your practices, regardless of whether you have made changes.

Coding the Visit Using 1995 and 1997 E&M Coding Rules

Once all work has been done to generate the charting note, return to the VISIT tab.
Confirm that Patient Type is correct and that Level of Visit reflects your judgement.
Check the Menu Bar to see if the status stoplight is green. If so, this indicates that the level of documentation is sufficient for your selected level of visit. Under the stoplight you can see the level determined by Net Health Employee Health and Occupational Medicine. Compare that with the choice beside Level of Visit. It may be that you have documented to a higher level than the selected level and you need to move the level up and thus avoid undercoding!
If the light is red, there is work still to be done, and there are three possible courses:
- You may decide Net Health Employee Health and Occupational Medicine is correct and that the Level of Visit has been set for a higher level that it should be. If so, change Level of Visit to the lower level and confirm that the documentation can support that.
- If you disagree, it may be that you can improve the documentation sufficiently to support the selected level of visit. In the section labeled Current Overall Compliance Documentation there are three areas of documentation. To the right of each area you can see the Documentation Required and the Currently Documented Level. Areas of documentation that are not sufficient for the selected level of visit will be red instead of green. Improving the documentation in the deficient areas can bring the documentation up to the needed level. The section below on the Audit button explains how you can get more information on how Net Health Employee Health and Occupational Medicine made its determination.
  
  Documentation sufficient for Level of Visit:
- It may be that you disagree with Net Health Employee Health and Occupational Medicine and are confident that current documentation supports your opinion. Because of the very many variables which factor into this decision, judgment is the ultimate authority. In this case, proceed with the instructions below to code the visit as you think it should be.

Read the topic on E/M Calculations to learn more about how Net Health Employee Health and Occupational Medicine determines the E/M level.

Click the E/M Coding button to display the [Code This Visit] window.
Accept the selected code that is based on Net Health Employee Health and Occupational Medicine's E/M calculations or change it as you believe appropriate.
Click OK to add the charge record to the visit. If there is already an E/M charge associated with the visit, it will be changed to the one you selected here. Visit charges can be seen on the PROCEDURES tab.

Coding the Visit Using 2021 E&M Coding Rules

For a video demonstration of the 2021 E&M Coding Time Based and Medical Decision Making changes, click here.

Once all work has been done to generate the charting note, return to the VISIT tab.
Confirm that Patient Type is correct and that Level of Visit reflects your judgement.
Check the Menu Bar to see if the status stoplight is green. If so, this indicates that the level of documentation is sufficient for your selected level of visit. Under the stoplight you can see the level determined by Net Health Employee Health and Occupational Medicine. Compare that with the choice beside Level of Visit. It may be that you have documented to a higher level than the selected level and you need to move the level up and thus avoid undercoding!
If the light is red, there is work still to be done, and there are three possible courses:
- You may decide Net Health Employee Health and Occupational Medicine is correct and that the Level of Visit has been set for a higher level that it should be. If so, change Level of Visit to the lower level and confirm that the documentation can support that.
- If you disagree, it may be that you can improve the documentation sufficiently to support the selected level of visit. In the section labeled Current Overall Compliance Documentation there are three areas of documentation. To the right of each area you can see the Documentation Required and the Currently Documented Level. Areas of documentation that are not sufficient for the selected level of visit will be red instead of green. Improving the documentation in the deficient areas can bring the documentation up to the needed level. The section below on the Audit button explains how you can get more information on how Net Health Employee Health and Occupational Medicine made its determination.
  
  Documentation sufficient for Level of Visit:
- It may be that you disagree with Net Health Employee Health and Occupational Medicine and are confident that current documentation supports your opinion. Because of the very many variables which factor into this decision, judgment is the ultimate authority. In this case, proceed with the instructions below to code the visit as you think it should be.
- Extent of Time may be added, edited, or deleted using the EMR Charting space under the Visit tab. For more information, see Using Net Health Employee Health and Occupational Medicine Charting Templates - Visit

Read the topic on E/M Calculations to learn more about how Net Health Employee Health and Occupational Medicine determines the E/M level.

Click the E/M Coding button to display the [Code This Visit] window (New Patient).
Under the E&M 2021 Rules for new patients, users may code using a time-based calculation (in 15 minute increments) or MDM based calculations. The software will recommend one or the other based on the activity recorded for the visit.

If Time Based is selected and the amount of time is over the max threshold and they can add the prolonged service codes, users may add more information regarding the correct CPT code which is displayed at the bottom of the Code this Visit window.

Users may only down-code the visit. Once this data is saved, the system creates charges on the billing statement. The only way to remove the charges is to use the billing procedures to delete the charges.
Accept the selected code that is based on Net Health Employee Health and Occupational Medicine's E/M calculations or change it as you believe appropriate.
Click OK to add the charge record(s)to the visit. If there is already an E/M charge associated with the visit, it will be changed to what was selected here. Visit charges can be seen on the PROCEDURES tab.

The Audit Window- Evaluation Tab

Clicking the Audit E&M button displays the [Audit Current Visit Evaluation] window which provides information about how Net Health Employee Health and Occupational Medicine determined the level of visit. It can be used to spot areas where documentation can be improved to increase the level of the visit.

Histories Sub-tab (1995 and 1997 Guidelines only)

Chief Complaint and HPI: Evaluation Level is determined by a simple count of elements documented plus the number of chronic conditions. The various elements are shown in light grey with a check beside those which have been documented. Chronic conditions are calculated based on entries in the setup of Templates and Wizards.

Extent of History Taken: Evaluation Level is determined by a simple count of elements documented.

Systems Reviewed: The Evaluation Level is determined by a simple count of elements entered on the ROS tab.

Examinations Sub-tab (1995 and 1997 Guidelines only)

Extent of Exam: Systems and Elements (bullet points) Examined: Bullet points are entered in the setup on the EXAM tab of Templates and exam Wizards. Accurate assignment of bullet points is critical to accurate calculations. The light gray list of EXAM elements above shows a check beside each one documented. Multiple exams can be run for a single element. The black list shows the number of bullet points tallied for each element. The total bullet point count for all exams is shown in the bottom left of this area. The 1995 methodology and the 1997 methodology are different and can reach different counts and levels, as seen in the example above. There is a setting in the EMR Parameters which tells Net Health Employee Health and Occupational Medicine to use the 1995 level, the 1997 level, or to use whichever is highest for this visit. Using the best level is the default.

Medical Decision Making Sub-tab using 1995 and 1997 E&M Coding Rules (includes Consult, Prevent, and Telephone visits)

The E&M Coding rules being used are indicated in the bottom left of the window.

Medical Decision Making Sub-tab using 2021 E&M Coding Rules (excludes Consult, Prevent, and Telephone visits)

The E&M Coding rules being used are indicated in the bottom left of the window.

Complexity of Medical Decision Making:

During the setup process, the provider can assign risk levels, problem and diagnostic test counts, and other factors such as chronicity, to EMR wizards and template items. During the Net Health Employee Health and Occupational Medicine EMR charting process, if something is not accounted for properly by the automatic calculations, the provider can override certain factors, based upon his/her expert knowledge, to make the level of MDM complexity more exact. This section summarizes the combined information from templates and Wizards run on ASSESSMENT, ORDERS, and PROCEDURES tabs. How these factors combine to determine the three risk level (Presenting Problems, Diagnostic Procedures, and Management Options) is complex. The Table of Risk, taken from the AMA publication, and found in the topic on How Net Health Employee Health and Occupational MedicineMakes E/M Calculations summarizes the requirements for each risk level in each of the three areas.

The topic on How Net Health Employee Health and Occupational Medicine Makes E/M Calculations tells more about how all these sub-groups are combined to determine the overall E/M level for the visit.

Time Sub-tab using 2021 E&M Coding Rules (excludes Consult, Prevent, and Telephone visits)

The E&M Coding rules being used are indicated in the bottom left of the window.

This tab allows users to view and edit entered visit time. Face-to-Face time and Non-Face-to-Face time is factored into the patient time calculations.

Provider Time Spent with Patient (Face-to-Face) may be entered either manually. Editing the information, is permitted; however, you may not add entries or delete them;

Provider Time Spent with Patient (Non-Face-to-Face) may be entered only through a wizard. Editing the information, is permitted; however, you may not add entries or delete them.

The Audit Window- Charting Elements Tab

If you want even more details about how Net Health Employee Health and Occupational Medicine arrived at its level for the visit, clicking the CHARTING ELEMENTS tab will display a list of every element that has been charted for the visit. That is, for every button that was clicked, with activity was entered, there will be an item on this list. For each item, the related button is identified and certain coding related information is displayed, all in a table for quick referencing.

Double-click an item to view the [View Patient Charting History Record] window with all details on that item. This window includes a Credentials button which displays information about the user who entered this record.

The Audit Window- Alerts Tab

The Alerts tab will display any current Alerts associated with this patient. The Alert could be from standard Wizard text or can be customized by the user within the Wizard. The Alert , Alert Type, Response Type, and the Practitioner will be displayed.

The Audit Window - Audit Tab

The Audit tab allows providers the opportunity to review the Additions, Modifications, and Views for their patient record. To display the details of a record, providers may highlight a row and double-click or highlight a row and select the View Audit Record button.

The following window will display:

Modifications: The software will denote the Workspace tab that is affected in red text. The Before and After tab can be used to show the extent of what part of the record was modified.

Additions: Tabs to which data was added will show the new information and the user who added it.

View: Tabs to which data has been viewed will show the new information and the user who viewed it.

The following CMS limitations are part of the calculation algorithms for an individual visit:

Self-limited or minor problems are limited to two problem points.
New problems without additional workup are limited to three problem points (i.e. a single problem of this classification).
Lab orders or reviews are limited to one data point.
Radiology orders or reviews are limited to one data point.
Medicine orders or reviews (i.e. all other orders in the diagnostic test orders and results sections) are limited to one data point.
Discussing tests with physician is limited to one data point.
Decision to obtain old records is limited to one data point.
Review of old records is limited to two data points (one review).
To support these calculation refinements, the EMR Wizard Setup area uses the following algorithms:
Wizards in the MDM Diagnostic Test Results, Diagnostic Test Orders and Other Data Sources now allow the user to classify the type of data source on the E&M Coding tab in the setup form. (The system will automatically attempt to classify lab, radiology and medicine orders based upon the existing check-out action and description of the wizard).
Diagnostic Test Results now allow assignment of data source points and risk levels on the E&M Coding tab.
Patient Instructions now allow assignment of risk levels on the E&M Coding tab (although point counting is not applicable).
The process of entering an assessment (diagnosis) will automatically assign the correct problem count limitations, based upon the options indicated by the physician during charting.
The EMR Charting Audit, MEDICAL DECISION MAKING tab displays the coding in a clear and organized way by splitting out the Problem count/limits and the Data count/limits.

For the newly refined calculations to take effect, the EMR setup users must modify any existing wizards in the MDM Diagnostic Test Results, Other Data Sources, and Instructions sections to mark applicable wizards with their appropriate classification on the E&M Coding tab. Any Wizards that remain unclassified with respect to data source type will continue to be calculated at face value based upon their original point count assignments.