You can base the Evaluation and Management (E&M) code calculation on the selected Medical Decision Making (MDM) level or on the total visit time.
- Open the FTS Finalize template and expand the Evaluation and Management Coding panel.
- In the Medical Decision Making section, do one of the following:
- Review prepopulated or manually 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 section.
The Medical Decision Making section shows 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 how to use the 2021 Coding guidelines based on MDM level and time, click the information
icon. To view MDM guidelines, click the View MDM Guidelines link.
- To calculate an E&M code based on the total visit time, click the Time (min) field, enter the total time in minutes including counseling time, and then click OK.
The minimum time is 15 minutes for a new patient and 10 minutes for an existing patient. The application selects the corresponding code in the code options section at the bottom of the Evaluation and Management Coding panel. The code appears in the first Visit code field and in the Calculated E&M field.