History and Physical Exam Levels and Assigned Points in the E&M Level Summary

Section or Field	Description
Calculated history level and Calculated Exam level	Shows a description of the level. For example, Problem Focused, Expanded Problem Focused, Detailed, or Comprehensive. The application determines the level based on the number of assigned points.
History of present illness	Shows either the total number of points for up to eight HPI elements that are documented, or the total number of chronic conditions that are documented with a status. If three or more chronic conditions have a status, the Detailed level of HPI field appears, replacing the HPI field.
Past medical, family, social history	Shows the total number of points for the Medical, Family, and Social history types, with one point assigned per history type.
Review of systems	Shows the total number of points for up to fourteen organ systems that are discussed with the patient.

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

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. You can view the following information in History Details. Section Description History of presenting illness Shows one point assigned for each of eight HPI elements that are documented. Chronic Conditions Shows the points assigned for the chronic conditions that are documented in today's assessment. The application assigns one point to each chronic condition. PMFSH Shows one point assigned for each of the three (past medical, family, and social) history types that are documented. Review of Systems Shows one point assigned for each of up to fourteen organ systems that are discussed with the patient. Note: Review of systems refers to the systems discussed, not examined. Parent topic: History Details on Finalize

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

NextGen® Adaptive Content Engine Help Enterprise 8

Chronic Conditions and Status

Under the 95 and 97 Coding Guidelines, the E&M calculation for chronic conditions occurs when you add a Chronic Condition and Status to the Today's Assessment field. The application assigns a field value of 1 to the shared audit fields for each chronic condition documented with a status. The detailed E&M history audit fields on the Finalize template also track where the chronic conditions were documented. E&M Level Summary The Chronic conditions field in the E&M Level Summary panel indicates the total chronic conditions count. If the count is 3 or more, the application calculates an extended HPI. The Chronic Conditions From Today's Assessment field in the History Details panel totals the Chronic Condition with a documented Status that were added to Today's Assessment. For more information on how to document chronic conditions, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide for NextGen® Adaptive Content Engine. Parent topic: Components of

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

Patient's History Summary

You can add, update, delete, and review a patient's history summary details from the History Summary panel. You can document a patient's history information in the History Summary panel in the following categories: Past Medical/Surgical Interim Social Family Diagnostic History Summary The Social Determinants of Health and PRAPARE® links appear based on the settings in the PRAPARE® section of the Practice Configuration template. Social Determinants of Health enables the documentation of social, behavioral, and psychological data for the patient. For more information about these settings, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Based on the patient's age, the Confidential link enables you to view and enter the confidential information provided by the patient during the encounter. The History Summary panel displays the patient history documented on the Histories template. You can als

History and Physical Exam Levels and Assigned Points in the E&M Level Summary

Recommendations

E and M Level Summary

Points Assigned to History Details

History Details on Finalize

Chronic Conditions and Status

Components of E&M Coding

Patient's History Summary

E and M Level Summary

Points Assigned to History Details

History Details on Finalize

Chronic Conditions and Status

Components of E&M Coding

Patient's History Summary