History of Present Illness

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Past, Family, and Social History Calculations

Under the 95 and 97 Coding Guidelines, NextGen® Adaptive Content Engine gives credit for E&M calculations for PFMSH when the following options have been selected on templates: Detailed document Reviewed, no changes Reviewed, updated History unobtainable Note: On the Document Configuration practice template, you can select a checkbox to Default Histories to "Reviewed, no changes" when the associated template is opened. Document Configuration template These options correspond to history radio buttons that are native to the Master_IM table and are shared on templates throughout NextGen® Adaptive Content Engine. Each native option updates a corresponding hidden field. These hidden fields are mapped to an EM Bullet ID on the E&M Bullets and Field Mapping system template. The bullet IDs associated with PFMSH are as follows: em_pmh em_fh em_sh For more information, go to NextGen Healthcare Success Community, and download the E&M Bullets and Field Mapping System Template for NextGen® Adaptive

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Physical Exam Elements for Evaluation and Management Coding

Under the 95 and 97 Coding Guidelines, each relevant exam field on the physical exam templates has been assigned an EM Bullet ID on the E&M Bullets and Field Mapping system template. This template stores all 95 and 97 E&M Coding Guidelines for Multi-and Single-system exams and their field mappings. A stored procedure and additional triggers on the Finalize template and on the Coding OPH template for NextGen® Adaptive Content Engine, 8.4.3 or earlier, total the field mappings for each system and calculate the suggested exam level component of E&M coding. For more information, go to NextGen Healthcare Success Community, and download the E&M Bullets and Field Mapping System Template for NextGen® Adaptive Content Engine. Show Single-system Physical Exam Field Mappings You can view single-system physical exam field mappings on the Evaluation and Management (E&M) bullets and field mapping system template for 97 coding guidelines. Parent topic: Components of Evaluation and Management Coding

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Review of Systems Calculation for Evaluation and Management Coding

The ROS information factors into the calculations under the 95 or 97 coding guidelines. All ROS symptoms are shared fields from the Symptom Master template or Symptom Master2 template. These fields are shared with both the History of Present Illness and Review of Systems templates. By using a single shared table, you do not have to reenter symptoms on a Review of Systems template if they were documented on a History of Present Illness template. For example, if positive for fever has been entered on a History of Present Illness template, it has also been filled on the appropriate Review of Systems template and appears in the ROS data grid. You can copy the previous review of systems information to the current encounter, select ROS History. The Historical Information window opens, select Copy ROS & Close to copy previous review of systems information to the current encounter on the SOAP template. You can give the E&M coding credit for ROS to the symptom from a History of Present Illness

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Finalizing Evaluation and Management Coding for an Encounter

Because the E&M guidelines are not always clearly defined, and comments cannot be included in the E&M calculations in NextGen® Adaptive Content Engine, the overall E&M level is only suggested. As the physician or provider performing the encounter, you must review and confirm the E&M code before you submit it for billing. The Finalize template calculates the E&M code based on the selected E&M coding guidelines on the Practice Configuration template. Under the 95 and 97 Coding Guidelines, the Finalize template offers the following functionality: The template totals the E&M components documented in the encounter. When you select Calculate Code, several stored procedures calculate the components. The application then suggests an E&M level for the encounter. You can override the suggested E&M level code by selecting an E&M code listed on the template. You can use the second and third visit code fields to enter additional E&M codes from a Service Category list or from lists you access throug

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Chronic Conditions and Status

Under the 95 and 97 Coding Guidelines, the E&M calculation for chronic conditions occurs when you add a Chronic Condition and Status to the Today's Assessment field. The application assigns a field value of 1 to the shared audit fields for each chronic condition documented with a status. The detailed E&M history audit fields on the Finalize template also track where the chronic conditions were documented. E&M Level Summary The Chronic Conditions field in the E&M Level Summary panel indicates the total chronic conditions count. If the count is 3 or more, the application calculates an extended HPI. The Chronic Conditions From Today's Assessment field in the History Details panel totals the Chronic Conditions with a documented Status that were added to Today's Assessment. For more information on how to document chronic conditions, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. Parent topic: Components of Evalua

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

EM Bullet ID - Field Mapping

The EM BULLET ID -FIELD MAPPING or Page 2 (Mapping) maps the EM Coding Bullet ID to a specific field on template. If any of the mapped fields are documented during an encounter, the EM Bullet ID is tallied with other bullets. A total tally of all documented bullets is shown on the EM History template. If new templates are added, or if existing templates are customized, and they contain HPI, or physical exam fields, the fields need to be mapped using Page 2 (Mapping) section of the E&M Bullets and Field Mapping template to be included in the EM calculation. For HPI’s, it is recommended that you use an existing HPI template as your starting point to minimize the need for EM mappings. For the history fields, it is recommended that you share the radio buttons and doc gen hidden fields from Master_IM onto your new template. By doing so, no additional mappings are needed. Mapping Data Grid Add a New Bullet ID - Field Mapping Remove a Bullet ID - Field Mapping Parent topic: Evaluation and Man

History of Present Illness

Recommendations

Past, Family, and Social History Calculations

Physical Exam Elements for Evaluation and Management Coding

Review of Systems Calculation for Evaluation and Management Coding

Finalizing Evaluation and Management Coding for an Encounter

Chronic Conditions and Status

EM Bullet ID - Field Mapping

History of Present Illness

Past, Family, and Social History Calculations

Physical Exam Elements for Evaluation and Management Coding

Review of Systems Calculation for Evaluation and Management Coding

Finalizing Evaluation and Management Coding for an Encounter

Chronic Conditions and Status

EM Bullet ID - Field Mapping