Data Review

NextGen® Orthopedic Suite Help 80.2.14.0

Document Diagnosis Management

Select one or more diagnoses from the Diagnosis grid to enter them in the B-Diagnosis/Mgmt section. Diagnosis Management on the Billable Visit template For each diagnosis in the B-Diagnosis/Mgmt section, select an option to describe the diagnosis: Self lim- self-limiting Est Stab– established, stable Est Wors– established, worse New New WU- new with work up The E&M points appear in the fields after the diagnosis descriptors. Parent topic: Assessment and Plan Panel (Diagnosis/MDM)

NextGen® Orthopedic Suite Help 80.2.14.0

Assessment and Plan Panel (Diagnosis/MDM)

The Assessment and Plan panel has three sections to match E&M coding guidelines: Diagnosis/Management, Data Review, and Risk of complications. These allow the provider to document Medical Decision Making. The system calculates and records points for Diagnosis/Management and Data Review and assigns a level for Risk of complications based on your recorded plan to treat the patient. All of these are used to calculate the final E&M code. Assessment and Plan panel on the Billable Visit template Add a New Diagnosis Document Diagnosis Management Data Review Risk of Complications - MDM Parent topic: Billable Visits

NextGen® Orthopedic Suite Help 80.2.14.0

Generate the E&M Code

In the lower part of the Assessment and Plan panel, click the E&M Key button to generate the E&M code. This searches the entire visit, the History, Exam and Assessment and Plan sections, verifying what information has been entered (noting the green indicators), to determine a suggested E&M code. E and M code on the Billable Visit template The system gives a value (or points) for History, Exam, and MDM, and a Final Code based on the information documented. Note: If you update histories, exams or MDM after clicking the E&M Key button, click the button again to update the code. View E&M Summary and Coding Guidelines You can view the details of a patient's visit, medical decision making (MDM), and evaluation and management (E&M) coding guidelines. Parent topic: Billable Visit Sign-off

NextGen® Adaptive Content Engine Help Enterprise 8

Review and Modify Medical Decision Making Levels

You can review and determine the complexity of a patient's health from the overall medical decision making (MDM) level. Before you begin Ensure that 2021 Coding Guidelines are effective. You can determine the overall medical-decision-making level of a patient by reviewing and changing the calculated medication decision making (MDM) levels obtained from MDM elements. Open NextGen® Enterprise EHR. On the Finalize template, expand the Medical Decision - Making Elements panel. The Medical Decision - Making Elements panel displays the automatically-calculated MDM level. Note: Future lab/X-ray orders placed in the current encounter are given credit to calculate the # of each unique test ordered element under MDM table B. Therefore, you must not consider these orders for calculating the # of each unique test reviewed element under MDM table B in future encounters. Note: Only some of the MDM elements in the tables are selected automatically. Review the selected elements and if necessary, modif

NextGen® Orthopedic Suite Help 80.2.14.0

Document Treatment Plans

In the Assessment and Plan panel, click a Medication Decision Making # link. Medication Decision Making on the Billable Visit template The IORTSMDM 1 template opens. IORTS MDM template Select one or more of Today’s Diagnoses in the upper left. Note: You can associate one diagnosis or multiple diagnoses with a plan. You can have up to eight different plans with eight different diagnoses if desired. Enter plan details for the diagnoses. You can enter data in the following ways: Click Get Data to fill the fields with information from a previous encounter with this patient. Click the Star or Double Star button in the QuickPick toolbar to load a template default. Select appropriate options, click the fields to select entries from picklists, or type the information in the field. Enter any check-out information using the C/O Info button. Enter in Follow-Up visit information and click Upload NV to send follow-up visit information to the Check Out template. Click Save & Close to return to the B

NextGen® Adaptive Content Engine Help Enterprise 8

Finalize Template

The Finalize template allows the provider to calculate all of the elements that were documented in the Intake, Histories, and SOAP tabs, select the Evaluation and Management (E&M) code level for the visit, and submit the E&M coding to the Superbill module. Patient's General Information on Finalize You can view the general details related to finalizing the workflow of the patient in the General panel. Patient's Assessments on Finalize You can view, add, or edit patient assessments in the Today's Assessment panel. Provider Sign Off 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. 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. Evaluation and Management Guidelines on Finalize Y

Data Review

Recommendations

Document Diagnosis Management

Assessment and Plan Panel (Diagnosis/MDM)

Generate the E&M Code

Review and Modify Medical Decision Making Levels

Document Treatment Plans

Finalize Template

Document Diagnosis Management

Assessment and Plan Panel (Diagnosis/MDM)

Generate the E&M Code

Review and Modify Medical Decision Making Levels

Document Treatment Plans

Finalize Template