Physical Exam Elements for E&M Coding

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

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

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

Show Single-system Physical Exam Field Mappings

Under the 97 Coding Guidelines, you can view physical exam field mappings on the E&M Bullets and Field Mapping system template for the following Single systems: Ears, Nose, and Throat (ENT or Otolaryngology); Dermatologic; Genitourinary; Musculoskeletal; Neurological; and Psychiatric. For more information about field mapping, go to NextGen Healthcare Success Community, and download the latest E&M Bullets and Field Mapping System Template for NextGen® Adaptive Content Engine. Open the E&M Bullets and Field Mapping system template. Click the Page 2 (Mapping) link. The EM BULLET ID - FIELD MAPPING section appears. All guidelines and Bullet IDs for these exams have been entered on the E&M Bullets and Field Mapping system template in this section. From the EM Type list, select the Single-system exam type. Single-system exam selection Click the Page 3 (Fields) link. The field mappings associated with the selected EM Type appear. EM Type field mappings Parent topic: Physical Exam Elements for

NextGen® Adaptive Content Engine Help Enterprise 8

Evaluation and Management Bullets and Field Mapping System Template

The E&M Bullets and Field Mapping system template enables you to create and manage Evaluation and Management (EM) codes within the NextGen® Adaptive Content Engine. Evaluation and Management Codes EM Coding Bullets EM Bullet ID - Field Mapping EM Field Maps Section EM Table List Parent topic: System and Practice Templates Related concepts Evaluation and Management Codes EM Coding Bullets EM Bullet ID - Field Mapping EM Field Maps Section Related reference EM Table List

NextGen® Adaptive Content Engine Help Enterprise 8

EM Coding Bullets

The EM CODING BULLETS or Page 1 (Bullets) section is pre-loaded with all the Evaluation and Management (E & M) Guidelines for all HPI elements, ROS elements, Histories elements, and Exam types found in the NextGen® Adaptive Content Engine. The system assigns each element a bullet ID based on the Centers for Medicare and Medicaid Services (CMS) Guidelines. EM Coding Bullets Data Grid Add New EM Coding Bullets Update an EM Coding Bullet Delete an EM Coding Bullet Parent topic: Evaluation and Management Bullets and Field Mapping System Template

Physical Exam Elements for E&M Coding

Recommendations

History of Present Illness (HPI)

Past, Family, and Social History (PFMSH) Calculations

Finalizing E&M Coding for an Encounter

Show Single-system Physical Exam Field Mappings

Evaluation and Management Bullets and Field Mapping System Template

EM Coding Bullets

History of Present Illness (HPI)

Past, Family, and Social History (PFMSH) Calculations

Finalizing E&M Coding for an Encounter

Show Single-system Physical Exam Field Mappings

Evaluation and Management Bullets and Field Mapping System Template

EM Coding Bullets