Submit E&M Codes per the 2021 Coding Guidelines

You can submit a calculated or selected Evaluation and Management (E&M) code to the Superbill using the 2021 Coding Guidelines.

1. From an encounter, select the Templates icon.
   The Select Template window opens.
2. On the Medical Records tab, select All.
   A list of all medical record templates appears.
3. Open the Finalize (BH) template and expand the Evaluation and Management Coding panel.
4. Enter a start and end time.
   The Duration appears. When you enter a start and end time, the Time (min) field is updated with the same value, and the application selects the corresponding E&M code in the code options section. The code appears in the first Visit code field and in the Calculated E&M field. You can modify the Time (min) value, which overrides the original duration time captured. Manually, entering a new value in the Time (min) field calculates a new E&M code.
5. Optional: To select an E&M code based on MDM, select one of the Medical Decision Making options.
   Note: You cannot select the code 99201. The code is expired effective January 1, 2021.

   The 99211 Nurse Visit code cannot be calculated based on the MDM level or time. You must select the code manually.

   For the codes 99205 and 99215, if the time exceeds the threshold of 74 minutes for a new patient or 54 minutes for an established patient, you can add a prolonged time code to report the additional time.

   The application clears the Time (min) field and selects the corresponding E&M code in the code options section, overriding the initial code selection based on time.
6. To access the Today's Orders, Given to Patient/Verified, and Patient Education panels, select the Checkout Popup link.
7. To enter additional visit codes, do one of the following:
   • Select the second or third Visit code field, and then select a code from the list.
     Note: You can update the items in the Visit Code Service Category list under Service Categories in File Maintenance.
   • To enter an E&M, behavioral health, or Medicare preventive code, select the corresponding link, and then select a code.
8. To meet the visit code criteria for Quality Reporting, select a SNOMED CT^® code.
9. To generate a note, referral, lab order or requisition, or another document, select Generate Note, and then select an option.
10. Select Submit Code.
    A Submitted message appears and the code appears in the Billed Codes grid.

    The application creates the Psychiatric Evaluation or Psychiatric Progress Note document, or other documents based on your practice configuration. For more information, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide forNextGen®Adaptive Content Engine and Document Configuration Practice Template Guide for NextGen® Adaptive Content Engine.

    Note:

    • To remove a charge submitted in error, see the Using Billed in Error section.
    • To access the Today's Orders, Given to Patient/Verified, and Patient Education panels, select the Checkout Popup link.