Chronic Conditions and Status

NextGen® Adaptive Content Engine Help Enterprise 8

Review of Systems (ROS) Calculation for E&M 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, click ROS History. The Historical Information window opens, click 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

History of Present Illness (HPI)

Under the 95 and 97 Coding Guidelines, HPI coding calculates the number of items selected in each of the HPI sections on templates. When an element is selected, the application assigns a value of 1 to a hidden E&M field corresponding to that section. The eight HPI hidden E&M fields are as follows: loc/rad (em_loc_rad) quality (em_qual) sev/size (em_sev_size) onset (em_onset) dur/freq (em_dur_freq) context (em_contxt) agg/rel (em_agg_rel) ass. SX (em_ass_sx) Each of these eight HPI fields has been mapped to an EM Bullet ID on the E&M Bullets and Field Mapping system template. The EM Bullet IDs are used to total the HPI points using a stored procedure on the Finalize template or on the Coding – OPH template for NextGen® Adaptive Content Engine, 8.4.3 or earlier. For more information, go to NextGen Healthcare Success Community, and download the latest E&M Bullets and Field Mapping System Template for NextGen® Adaptive Content Engine. Parent topic: Components of E&M Coding

NextGen® Adaptive Content Engine Help Enterprise 8

Finalizing E&M 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 codes 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

Components of E&M Coding

The calculation of evaluation and management (E&M) code is based on following components. E&M Coding Component Description New Patient or Established Patient Required. This component identifies which patient type is used for the overall E&M calculation. A new patient has not received any professional services from any physician in the same specialty within a group over the last three years. Visit Type Required. The visit type identifies the E&M code category, for example, Office Visit, Consultation Visit, or Preventive Visit. The visit type factors into all coding guidelines. Reason for Visit (RFV) or Chief Complaint (CC) Required. The RFV describes the symptom, problem, condition, or diagnosis that indicates why the patient has come for services. The RFV factors into the calculations under the 95 or 97 Coding Guidelines. History of Present Illness (HPI) The HPI factors into the calculations under the 95 or 97 Coding Guidelines and documents any of the following elements: Location Dura

NextGen® Adaptive Content Engine Help Enterprise 8

E and M 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

History Details on Finalize

You can view the coding points assigned to each element of the patient's history component under the 95 or 97 Coding Guidelines in the History Details panel. The coding points are factored into the calculation of the Evaluation and Management (E&M) code under the 95 or 97 Coding Guidelines. If the 2021 Coding Guidelines are in effect, you can refer to this panel to review the history you documented; however, the history elements do not factor into the calculated E&M code. You can view the following information about history details. History of presenting illness Chronic conditions Past medical, family, and social history Review of systems Points Assigned to History Details You can view the points assigned to the history of presenting illness; chronic conditions; past medical, family, and social history; and review of systems in the History Details panel. Parent topic: Overview of the Finalize Template Workflow Parent topic: The Finalize Template Workflow Parent topic: Finalize Template

Chronic Conditions and Status

Recommendations

Review of Systems (ROS) Calculation for E&M Coding

History of Present Illness (HPI)

Finalizing E&M Coding for an Encounter

Components of E&M Coding

E and M Level Summary

History Details on Finalize

Review of Systems (ROS) Calculation for E&M Coding

History of Present Illness (HPI)

Finalizing E&M Coding for an Encounter

Components of E&M Coding

E and M Level Summary

History Details on Finalize