Evaluation and Management Coding

The Cardiology template set does not use these calculation methods described. For information on E&M coding for the Cardiology specialty, go to NextGen Healthcare Success Community, and download the Cardiology User Guide for NextGen® Adaptive Content Engine.

The 2021 Coding Guidelines apply to certain visit types that use codes 99202 to 99205 for a new patient and codes 99212 to 99215 for an established patient. Code 99201 expires effective January 1, 2021. Code 99211 is typically used for a nurse visit and does not have MDM or time criteria.

If you select the 2021 Coding Guidelines, you must also select either the 95 or 97 Coding Guidelines for visit types and encounters that do not fall under the 2021 Coding Guidelines.

Even with these guidelines, there are many elements that are not clearly defined. In January 2006, CMS published a memorandum stating that each local CMS carrier had permission to develop more definitive rules for the E&M billing where areas of the official guidelines were obscure. Many local carriers developed their own documentation and auditing standards for E&M coding.

Because the E&M coding guidelines may be vague, your practice is responsible for following the rules for your local Medicare and Medicaid carriers and other payer rules. Your practice must define unavailable areas within your organization through a compliance program. NextGen® Enterprise provides tools, such as the E&M Bullets and Field Mapping system template and other configuration options, to make necessary changes to the database.

NextGen® Adaptive Content Engine cannot incorporate every local carrier, payer, and individual group specification. In addition, NextGen® Enterprise cannot include text comments in the E&M calculations or check for errors in your selections, such as visit types or the MDM level. The overall E&M level can only be suggested.