History Details on Finalize

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Evaluation and Management Level Summary

You can view the summary of a patient's history, exam levels, and coding points for the Evaluation and Management (E&M) code calculation under the 95 or 97 Coding Guidelines in the E&M Level Summary panel. You can review the history and physical exam information on E&M Level Summary to see which elements factor into the calculation of the Evaluation and Management (E&M) code under the 95 or 97 Coding guidelines. On E&M Level Summary, you can view the following: Calculated patient history level Calculated physical exam levels Total number of points assigned to elements for history details 95 physical exam details, or 97 physical exam details for multiple systems or a single system If the 2021 Coding Guidelines are in effect, you can refer to E&M Level Summary to determine if you have documented a medically appropriate history and physical exam elements; however, the history and physical exam elements are not included in the calculation of the E&M code. The physical exam details informat

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Evaluation and Management Guidelines on Finalize

You can view different coding guidelines on the Finalize template. The guidelines are available as the following panels in the template. 95 Physical Exam Details displays the calculated E&M points for each listed component. 95 Physical Exam Details on Finalize 97 Multi System Physical Exam Details displays detailed information on calculating points for multi system physical exam items to calculate a total E&M service code. 97 Multi System Physical Exam Details on Finalize 97 Single System Physical Exam Details displays detailed information on calculating points for single system physical exam items to calculate a total E&M service code. You can only use one of these guidelines at a time. You need to configure the guidelines in the E&M Coding section on the Practice Configuration template. Note: With the 97 Coding Guidelines, you can select the Multi system or Single system physical exam type in the General panel on the Finalize template. Based on the selection, either the 97 Multi Syst

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Patient's General Information on Finalize

You can view the general details related to finalizing the workflow of the patient in the General panel. In the General panel, you can do the following: View the patient type. If other encounters exist for the patient, the Established patient option is selected, and if no other encounters exist, then the New patient option is automatically selected. You can also change the selected patient type. The calculated E&M codes are based on the patient type. View the type of guidelines (1995, 1997, or 2021) selected for Evaluation and Management (E&M) coding. Opens information on E&M guidelines for 1995 or 1997 from the Centers for Medicare and Medicaid Services (CMS) website, and for 2021 from the American Medical Association (AMA) website using the Web button. Select the physical exam type for multiple systems or a single system, if you turned on the 97 Coding Guidelines on the Practice Configuration template. In the General panel, if you select Single system, you need to select an exam type

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Overview of Evaluation and Management Coding

You can calculate and submit the E&M code. You can submit and calculate the Evaluation and Management (E&M) code from the Finalize template using the 95, 97, 2021 Guideline, or 2023 Coding Guidelines update based on the Practice Configuration template settings. The available E&M codes vary by specialty and visit type. If you do not want to charge a patient encounter, you can select the No Charge Visit checkbox in the Evaluation and Management Coding panel to submit a no-charge code. The No Charge Visit procedure group checkbox is configured by default. The No Charge Visit checkbox is available only if the no charge SIM code is configured to the No Charge Visit procedure group using the Manage Procedure Group and Codes template. For more information, go to NextGen Healthcare Success Community, and download the Manage Procedure Groups and Codes Practice Template for NextGen® Adaptive Content Engine. The 95 and 97 Coding Guidelines use the following E&M code calculation criteria: History

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

The Finalize Template Workflow

You can do the following on the Finalize template: Submit and review the plan of care, based on your role, on the Provider Sign Off panel. Document Evaluation and Management (E&M) codes on the Evaluation and Management Coding panel. Calculate the patient's medical-decision-making level and submit the E&M codes to the Superbill module. Review the patient's history and physical examination details on the E&M Level panel and identify factors in the calculation of the E&M code under the 95 or 97 Coding Guidelines. For more information on E&M coding, go to NextGen Healthcare Success Community, and download the E&M Coding User Guide for NextGen® Adaptive Content Engine. Patient's General Information on Finalize You can view the general details related to finalizing the workflow of the patient in the General panel. Patient's Assessments on Finalize You can view, add, or edit patient assessments in the Today's Assessment panel. Evaluation and Management Level Summary You can view the summary o

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Counseling Details

You can enter the counseling details for a patient and include them in the visit note. Open NextGen® Enterprise EHR. Open a patient record. Open the Finalize template. On Evaluation and Management Coding, select the Counseling Details link.The Counseling Details template opens. In the Counseling/Educational Details section, do the following: Select the counseling type, method, and evaluation.The counselor's name and date appear. Enter the time spent in patient counseling. Enter additional counseling information. Enter the type of educational materials the patient received. To enter details about an interpreter, select the corresponding checkbox, and then enter their language, name, and relationship with the patient. You can enter details for up to five types of counseling and education. Total counseling time (minutes) displays the sum of the total time entered for counseling sessions you entered. To indicate which counseling and educational factors appear in the visit note, do one of t

History Details on Finalize

Recommendations

Evaluation and Management Level Summary

Evaluation and Management Guidelines on Finalize

Patient's General Information on Finalize

Overview of Evaluation and Management Coding

The Finalize Template Workflow

Enter Counseling Details

History Details on Finalize

Evaluation and Management Level Summary

Evaluation and Management Guidelines on Finalize

Patient's General Information on Finalize

Overview of Evaluation and Management Coding

The Finalize Template Workflow

Enter Counseling Details