NextGen Knowledge Center

Evaluation and Management Coding

NextGen® Adaptive Content Engine uses Evaluation and Management (E&M) coding guidelines from the Centers for Medicare and Medicaid Services (CMS) for the documentation and billing of E&M services because these protocols are the most stringent. CMS provides three sets of guidelines to calculate E&M codes:
  • 1995 (95) Coding Guidelines
  • 1997 (97) Coding Guidelines
  • 2021 Coding Guidelines (effective January 1, 2021)

The Cardiology template set does not use these calculation methods described. For information on E&M coding for the Cardiology specialty, go to NextGen Healthcare Success Community, and download the latest Cardiology User Guide for NextGen® Adaptive Content Engine.

The 95 and 97 Coding Guidelines calculate E&M codes based on one of the following:
  • Documented history and physical exam elements and the selected Medical Decision Making (MDM) level
  • Total visit time if more than 50 percent of the time was spent counseling or coordinating care
You can use either the 95 or 97 Coding Guidelines depending on which is most advantageous to your practice.
The 2021 Coding Guidelines calculate E&M codes based on one of the following:
  • The selected MDM level
  • Total time spent on patient care and documentation for the visit, which includes face-to-face time with the patient and other time personally spent by the physician and/or other qualified healthcare professional on the day of the encounter
You can include counseling time in the total time, but the 2021 Coding Guidelines do not require that over 50 percent of the total time be spent in counseling or coordinating care.

The 2021 Coding Guidelines apply to certain visit types that use codes 99202 to 99205 for a new patient and codes 99212 to 99215 for an established patient. Code 99201 expires effective January 1, 2021. Code 99211 is typically used for a nurse visit and does not have MDM or time criteria.

If you select the 2021 Coding Guidelines, you must also select either the 95 or 97 Coding Guidelines for visit types and encounters that do not fall under the 2021 Coding Guidelines.

Even with these guidelines, there are many elements that are not clearly defined. In January 2006, CMS published a memorandum stating that each local CMS carrier had permission to develop more definitive rules for the E&M billing where areas of the official guidelines were obscure. Many local carriers developed their own documentation and auditing standards for E&M coding.

Because the E&M coding guidelines may be vague, your practice is responsible for following rules for your local Medicare and Medicaid carriers and other payer rules. Your practice must define gray areas within your organization through a compliance program. NextGen® Enterprise provides tools, such as the E&M Bullets and Field Mapping system template and other configuration options, to make necessary changes to the database.

NextGen® Adaptive Content Engine cannot incorporate every local carrier, payer, and individual group specifications. In addition, NextGen® Enterprise cannot include free text comments in the E&M calculations or check for errors in your selections such as visit types or the MDM level. The overall E&M level can only be suggested.