Calculate and Submit Evaluation and Management Codes Under the 2021 Coding Guidelines

You can calculate or select Evaluation and Management (E&M) codes for Cardiology for submission to the Superbill by using the 2021 Coding Guidelines from the Evaluation and Management Coding panel of the Cardiology Finalize template.

1. Open the Cardiology Finalize template, and then expand the Evaluation and Management Coding panel.
   

2. Review the patient's medications and diagnoses, and then to add or update the medication, select Add/Update.

   You must document at least one diagnosis to submit the Evaluation and Management (E&M) code.

3. To enter the counselling and educational details and factors, select Counsel Details.
   The Counseling Details template opens.
4. If you counsel a patient on tobacco cessation for longer than three minutes, select Tobacco Cessation, enter the relevant information in the Tobacco Cessation template, and then select Save & Close.
   Note: If you spend longer than three minutes on tobacco cessation counseling, the application submits a separate billing non-E&M code. You can document the tobacco cessation counseling details, but the time spent counseling the patient is not a factor in determining the E&M code.
5. Do one of the following:
   • To submit the E&M code calculated on the basis of Medical Decision Making (MDM), review the existing complexity level or manually select the level of complexity associated with the encounter in the Medical Decision Making section.

     The Medical Decision Making or Counseling section displays the prepopulated MDM level based on the calculated levels in the three tables in the Medical Decision - Making Elements panel. To change the prepopulated MDM level, you can change the automatically-calculated MDM levels in Medical Decision - Making Elements panel by selecting appropriate elements in the MDM tables, or by making corrections in the encounter chart note.

   • To submit the E&M code calculated on the basis of the total visit time, enter the total visit time.

     The minimum time is 15 minutes for a new patient and 10 minutes for an existing patient.

   The application fills the corresponding code in the EM Code section, and the code appears in Calculated.
6. To override the calculated code, select a specific code from the EM Code section.
7. Enter additional visit codes and corresponding modifiers.
8. Select the G2211 checkbox to bill on the new add-on code for the 99202, 99203, 99204, and 99205 codes.
   Note: You can select only the G2211 checkbox or Modifier(s) at a time.
9. To submit the code to the Superbill, select Submit Code.
   The submitted code appears in Submitted in the EM Code section. The Submitted line on the template displays the name of the submitter and the date and time of submission.