Review and Modify Medical Decision Making Levels

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Determining Medical Decision Making Levels

You can view the health complexity of the patient from the Medical Decision - Making Elements panel based on the diagnosis and HPIs details documented in the patient encounter chart note. Medical Decision Making (MDM) suggests the complexity level of the patient's health, based on the data points documented in the encounter chart note of the patient. You can review the MDM level and change the automatically-filled MDM elements. The suggestion of an MDM level helps you save the time spent on MDM and bill a claim with the appropriate E&M level. Note: The Medical Decision - Making Elements panel is available only if E&M 2021 Coding Guidelines are effective. For more information on the 2021 Coding Guidelines, go to NextGen Healthcare Success Community, and download the E&M Coding User Guide for NextGen® Adaptive Content Engine. You can review the selected MDM elements in the Medical Decision - Making Elements panel on the Finalize template, and select additional MDM elements in the three M

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Calculate E&M Codes under 2021 Coding Guidelines

You can calculate the Evaluation and Management (E&M) code under 2021 Coding Guidelines in Evaluation and Management. You can base the Evaluation and Management (E&M) code calculation on the selected Medical Decision Making (MDM) level or total visit time. Open NextGen® Enterprise EHR. Open a patient record. Open the Finalize template. On the Evaluation and Management Coding panel, to calculate the E&M code based on the MDM level, review the pre-filled complexity level or manually select the level of complexity associated with the encounter in the Medical Decision Making section.The Medical Decision Making section displays the MDM level based on the calculated levels in the three tables in the Medical Decision - Making Elements panel. To change the MDM level, change the automatically-calculated MDM levels in the MDM tables, or by making corrections in the encounter chart note. For guidance on using the 2021 Coding Guidelines based on MDM level and time, select the information icon. For

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Submit Evaluation and Management (E&M) Codes under the 2021 Coding Guidelines

You can submit a calculated or selected Evaluation and Management (E&M) code to the Superbill by using 2021 Coding Guidelines. Before you begin You must ensure that the encounter is on or after the effective start date of 2021 Coding Guidelines entered on the Practice Configuration template, and the visit type falls under the guidelines. For more information on the 2021 Coding Guidelines, go to NextGen Healthcare Success Community, and download the E&M Coding User Guide for NextGen® Adaptive Content Engine. Also, you must select an assessment in the Today’s Assessments panel to submit an Evaluation and Management (E&M) code. Open NextGen® Enterprise EHR. Open a patient record. Open the Finalize template, and expand the Evaluation and Management Coding panel. To use a calculated E&M code, review and select the Medical Decision Making (MDM) level or enter the total time. The Medical Decision Making section displays the MDM level based on the calculated levels in the three tables in the M

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Calculate E&M Codes under the 95 or 97 Coding Guidelines

You can calculate the Evaluation and Management (E&M) code under the 95 or 97 Coding Guidelines. You can base the E&M code calculation on the selected Medical Decision Making (MDM) level, documented history, and physical exam elements, or on the total visit time if more than 50 percent of the time was spent counseling or coordinating care. Open NextGen® Enterprise EHR. For a patient record, open a new encounter. Open the Finalize template. On Evaluation and Management Coding, do one of the following: To calculate the E&M code based on the MDM Level, documented history, and physical exam elements, select the level of complexity associated with the encounter in the Medical Decision Making section. For guidance in determining the level of complexity involved in MDM, you can select the View MDM Guidelines link and the level of risk associated with the encounter, select the View Risk link and refer to the details. To calculate the code based on the total visit time, do the following: Select

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Submit E&M Codes under 95 or 97 Coding Guidelines

You can submit a calculated or selected E&M code to the Superbill under the 95 or 97 Coding Guidelines. Before you begin You must select an assessment in the Today’s Assessments panel to submit an E&M code. Open NextGen® Enterprise EHR. For a patient record, open a new encounter. Open the Finalize template. Expand the Evaluation and Management Coding panel. Evaluation and Management Coding To use a calculated E&M code, you can select the MDM level, or enter the total visit time. Enter any additional visit codes. To meet visit code criteria for Quality Reporting, select a SNOMED® CT code. To override the calculated code, select an E&M code in the code options section at the end of the Evaluation and Management Coding panel. Note: The 99201 code cannot be selected as the code has expired on January 1, 2021. To generate a note, referral, lab order, requisition, or another document, select Generate Note and select an option. Select Submit Code.The code appears in the Submitted field. The a

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Calculate an E&M Code under 2021 Coding Guidelines on the Cardiology Finalize Template

To calculate an E&M code under the 2021 Coding Guidelines, you must select the Medical Decision Making (MDM) level or enter time on the EM 2021 Guidelines template that opens from the Cardiology Finalize template. To compare E&M codes, you can switch between the calculation methods. However, you cannot combine codes from both methods. The application uses the last calculated code. Open the Cardiology Finalize template and then expand the Evaluation and Management Coding panel. In the Medical Decision Making or Counseling section, do one of the following: Review prepopulated or select the level of complexity associated with the encounter. Enter the total visit time. To calculate the E&M code based on the MDM level, review prepopulated or select the level of complexity associated with the encounter in the Medical Decision Making or Counceling section. The Medical Decision Making section shows the MDM level based on the calculated levels in the three tables in the Medical Decision - Makin

Review and Modify Medical Decision Making Levels

Before you begin

Recommendations

Determining Medical Decision Making Levels

Calculate E&M Codes under 2021 Coding Guidelines

Submit Evaluation and Management (E&M) Codes under the 2021 Coding Guidelines

Calculate E&M Codes under the 95 or 97 Coding Guidelines

Submit E&M Codes under 95 or 97 Coding Guidelines

Calculate an E&M Code under 2021 Coding Guidelines on the Cardiology Finalize Template

Review and Modify Medical Decision Making Levels

Before you begin

Determining Medical Decision Making Levels

Calculate E&M Codes under 2021 Coding Guidelines

Submit Evaluation and Management (E&M) Codes under the 2021 Coding Guidelines

Calculate E&M Codes under the 95 or 97 Coding Guidelines

Submit E&M Codes under 95 or 97 Coding Guidelines

Calculate an E&M Code under 2021 Coding Guidelines on the Cardiology Finalize Template