Generating Evaluation and Management (E/M) Codes

Office level visits codes, both new and established are based on 3 categories, constructed from CMS guidelines: History, Exam, and Medical Decision Making.  Each of these categories is based on specific criteria that must be met to generate a suggested coding.

History is based on the following criteria:

• Review of Systems (ROS)
• History of Present Illness (HPI)
• Past Medical History (found in History of the Progress Note)
• Past Family History (found in History of the Progress Note)
• Social History (found in History of the Progress Note)

Exam is based on the following criteria:

• Vital Signs
• General
• Cardiovascular
• Neck
• Lymphatic
• Ears Nose Mouth
• Extremities
• Neurologic
• Psychiatric
• Oropharynx
• Eyes
• Gastrointestinal
• Skin

These criteria can be met by utilizing a combination of Vital Signs, ROS, and Physical Exam found in the Progress Note as well as using a Normal/Linear Exam (long hold on the red body map icon).

Medical Decision Making is based on the following criteria:

• Problem Points
• Data Points
• Risk

These criteria can be found in the Data Reviewed section of the Progress Note, the green dollar sign icon, or can be added within a treatment plan.  Risk is defined in Data Reviewed by selecting the red “i” on the far right side of each of the risk options.

Based on the information that is added in each of these sections, a suggested E/M code will be generated.  This code CAN be overridden after the note has been signed off, and is only an estimate of what the system should bill based on the information that was entered.

Each of these categories can be checked within Coding at the top of the Progress Note.  Tap each of the Categories to see how much of the criteria has been met

*PLEASE NOTE* All new patients must have Medical Decision Making documented in order for the system to generate an E&M Code.