Before you begin
To submit an E&M code, you must first select a diagnosis. For more information on diagnoses, go to
NextGen Healthcare Success Community, and download the latest
Cardiology User Guide forNextGen®Adaptive Content Engine.
- Open the Cardiology Finalize template and then expand the Evaluation and Management Coding panel.
- Review the patient's medications and diagnoses. To add or update the medication, click Add/Update.
At least one diagnosis must be documented to submit the Evaluation and Management (E&M) code.
- To enter the counselling and educational details and factors, click Counsel Details.
The Counseling Details template opens.
- If you counsel a patient on tobacco cessation for longer than three minutes, click Tobacco Cessation, enter the relevant information in the Tobacco Cessation template, and then click Save & Close.
Note: If you spend longer than three minutes on tobacco cessation counseling, the application submits a separate billing code (not an E&M code). You can document tobacco cessation counseling details, but the time spent counseling the patient is not a factor in determining the E&M code.
- To use a calculated E&M code, review and select the MDM level or enter the total time. For more details, see Calculate an E&M Code under 2021 Coding Guidelines on the Cardiology Finalize Template.
The Medical Decision Making section shows the prepopulated MDM level based on the calculated levels in the three tables in the Medical Decision-Making Elements panel.
- To override the calculated code, select a specific code from the EM Code section.
Note: Code
99201 expires effective January 1, 2021.
Code 99211 Nurse Visit cannot be calculated, so you must manually select it.
- Enter additional visit codes and corresponding modifiers.
- To submit the code to the Superbill, click Submit Code.
The submitted code appears in the Submitted field of the EM Code section. The Submitted line at the bottom of the template displays the name of the submitter and the date and time of submission.
