Before you begin
The date of the encounter must be on or after the effective start date entered for the 2021 Coding Guidelines on the Practice Configuration template. The visit type must fall under the guidelines. For information on the 2021 Coding Guidelines, go to the NextGen Healthcare Success Community and download the latest E&M Coding User Guide for NextGen® Adaptive Content Engine.
Also, you must select an assessment in the Today’s Assessments panel to be able to submit an E&M code
You can switch between selecting the Medical Decision Making (MDM) level and entering the total time to compare the code calculated by the application for each method and determine which to use before you submit the code. The application uses the last calculated code.
- For guidance on the level of complexity and risks involved in MDM, click the View MDM Guidelines link.
A window opens, describing the elements of MDM for each available E&M code and level along with the risks of complications and morbidity or mortality of patient management.
- For more information on the EM Coding guidelines, click the information icon.
If the patient was counseled, click the Counseling Details link and enter the counseling details.
- In the Medical Decision Making/Counseling panel, do one of the following:
- Select a complexity level.
- In the Time field, enter the total time in minutes spent with the patient and documenting the encounter.
The system uses the time entered here to calculate the
Prolonged Service code and units, when applicable. If Medicare is the encounter level insurance, the system automatically selects the
Medicare Beneficiary check box to activate the Medicare guidelines for the prolonged service code calculation.
Note: If Medicare is not present for the encounter level insurance, you can select the Medicare Beneficiary check box to apply the Medicare guidelines for prolonged service code calculation.
The appropriate office visit code is automatically selected in the EM Code panel and appears in the Calculated code field. The Calculate Code button is disabled.
- To manually select the code, you can select one of the options for New patient or Established.
Note: The medical complexity level and time appear next to each code. Time includes the total time spent on patient care and documentation for the encounter.
The selected code appears in the Calculated code field.
- To submit an eye code, select the appropriate code in the Eye Codes section.
The selected code appears in the Submitted code field.
- Click the Submit Code button to submit the code and billing.
The code is submitted to the Superbill and the Submitted message appears.
