You can calculate or select Evaluation and Management codes for Cardiology for submission to the Superbill using the 2021 Coding Guidelines from the Evaluation and Management Coding panel of the Cardiology Finalize template.
Before you begin
To use the 2021 Coding Guidelines, the encounter date must be the effective or a later date for the 2021 Coding Guidelines entered on the
Practice Configuration template. Also, the selected visit type must be configured as per 2021 Coding Guidelines from the
Card Setup Visit Type template.
- Open the Cardiology Finalize template and then expand the Evaluation and Management Coding panel.
- Review the patient's medications and diagnoses. To add or update the medication, click Add/Update.
At least one diagnosis must be documented to submit the Evaluation and Management (E&M) code.
- To enter the counselling and educational details and factors, click Counsel Details.
The Counseling Details template opens.
- If you counsel a patient on tobacco cessation for longer than three minutes, click Tobacco Cessation, enter the relevant information in the Tobacco Cessation template, and then click Save & Close.
Note: If you spend longer than three minutes on tobacco cessation counseling, the application submits a separate billing code (not an E&M code). You can document tobacco cessation counseling details, but the time spent counseling the patient is not a factor in determining the E&M code.
- Do one of the following:
- To submit the E&M code calculated on the basis of Medical Decision Making (MDM), review the prepopulated complexity level or manually select the level of complexity associated with the encounter in the Medical Decision Making section.
The Medical Decision Making or Counseling section displays the prepopulated MDM level based on the calculated levels in the three tables in the Medical Decision - Making Elements panel. To change the prepopulated MDM level, change the automatically-calculated MDM levels in Medical Decision - Making Elements panel by selecting appropriate elements in the MDM tables, or by making corrections in the encounter chart note.
- To submit the E&M code calculated on the basis of total visit time, enter the total visit time.
The minimum time is 15 minutes for a new patient and 10 minutes for an existing patient.
The application fills the corresponding code in the EM Code section, and the code appears in the Calculated field.
- To override the calculated code, select a specific code from the EM Code section.
- Enter additional visit codes and corresponding modifiers.
- To submit the code to the Superbill, click Submit Code.
The submitted code appears in the Submitted field of the EM Code section. The Submitted line at the bottom of the template displays the name of the submitter and the date and time of submission.
