History of Present Illness (HPI)

NextGen® Adaptive Content Engine Help Enterprise 8

Past, Family, and Social History (PFMSH) Calculations

Under the 95 and 97 Coding Guidelines, NextGen® Adaptive Content Engine gives credit for E&M calculations for PFMSH when the following options have been selected on templates: Detailed document Reviewed, no changes Reviewed, updated History unobtainable Note: On the Document Configuration practice template, you can select a check box to Default Histories to "Reviewed, no changes" when the associated template is opened. Document Configuration template These options correspond to history radio buttons that are native to the Master_IM table and are shared on templates throughout NextGen® Adaptive Content Engine. Each native radio button updates a corresponding hidden field. These hidden fields are mapped to an EM Bullet ID on the E&M Bullets and Field Mapping system template. The bullet IDs associated with PFMSH are as follows: em_pmh em_fh em_sh For more information, go to NextGen Healthcare Success Community, and download the latest E&M Bullets and Field Mapping System Template for Next

NextGen® Adaptive Content Engine Help Enterprise 8

Physical Exam Elements for E&M Coding

Under the 95 and 97 Coding Guidelines, each relevant exam field on the physical exam templates has been assigned an EM Bullet ID on the E&M Bullets and Field Mapping system template. This template stores all 95 and 97 E&M Coding Guidelines for Multi-and Single-system exams and their field mappings. A stored procedure and additional triggers on the Finalize template and on the Coding OPH template for NextGen® Adaptive Content Engine, 8.4.3 or earlier, total the field mappings for each system and calculate the suggested exam level component of E&M coding. 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. Show Single-system Physical Exam Field Mappings You can view Single-system physical exam field mappings on the E&M Bullets and Field Mapping system template for 97 Coding Guidelines. Parent topic: Components of E&M Coding

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

New and Established Patients and Visit Types

There are many different E&M Service categories such as Office Visits, Consultations, and Preventive Services. Most of these services are further categorized into New and Established patient services where the calculation of E&M levels begins in NextGen® Adaptive Content Engine. To calculate an E&M code, you must select a New or Established patient designation along with a description from the Visit Type list. Most, but not all, visit types are mapped to E&M codes. This mapping is used in the overall calculation of the E&M code. For example, visit types classified as office services are mapped to sick E&M codes 99201-99215. Preventive medicine visit types are mapped to preventive medicine E&M codes 99381-99397. For more information about E&M mappings, go to NextGen Healthcare Success Community, and download the latest E&M Bullets and Field Mapping System Template for NextGen® Adaptive Content Engine. Note: NextGen Healthcare strongly recommends that you do not add or delete items from

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

EM Bullet ID - Field Mapping

The EM BULLET ID -FIELD MAPPING or Page 2 (Mapping) maps the EM Coding Bullet ID to a specific field on template. If any of the mapped fields are documented during an encounter, the EM Bullet ID is tallied with other bullets. A total tally of all documented bullets is shown on the EM History template. If new templates are added, or if existing templates are customized, and they contain HPI, or physical exam fields, the fields need to be mapped using Page 2 (Mapping) section of the E&M Bullets and Field Mapping template to be included in the EM calculation. For HPI’s, it is recommended that you use an existing HPI template as your starting point to minimize the need for EM mappings. For the history fields, it is recommended that you share the radio buttons and doc gen hidden fields from Master_IM onto your new template. By doing so, no additional mappings are needed. Mapping Data Grid Add a New Bullet ID - Field Mapping Remove a Bullet ID - Field Mapping Parent topic: Evaluation and Man

History of Present Illness (HPI)

Recommendations

Past, Family, and Social History (PFMSH) Calculations

Physical Exam Elements for E&M Coding

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

New and Established Patients and Visit Types

Chronic Conditions and Status

EM Bullet ID - Field Mapping

Past, Family, and Social History (PFMSH) Calculations

Physical Exam Elements for E&M Coding

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

New and Established Patients and Visit Types

Chronic Conditions and Status

EM Bullet ID - Field Mapping