An optional encounter section is available named E&M Calculator. The section includes items contents to help calculate a billing code using E& M Calculator (Evaluation & Management).
Another optional encounter section is available named Billing and Charges. And that encounter section also includes E&M Calculator contents along with Time Factor capture.
E&M Calculator
The EM Calculator is a coding wizard that works when you manually change the dropdowns and will attempt to also auto-calculate but depends on the type of data and method of capturing that data in the encounter. However, it may not be able to auto-calculate is because when someone free-texts notes (such as the HPI, etc.) the calculator doesn’t know how many areas they are observing to count, or if they dictate in the exam the calculator can’t count that either because it doesn’t know what specific levels/areas/systems etc were dictated. That makes it impossible to auto-calculate a recommended code. The more areas that a physician touches/documents and examines, the more thorough and detailed the examination. The more thorough the examination is, the higher the level at which the physician can be reimbursed. Another component of an evaluation and management session is the assessment and planning. This is where the physician determines the diagnosis, the management options to care for this diagnosis, and the risks involved in treating this diagnosis. Also involved is the review of medical records and research in formulating the decision about the diagnosis and formulating the plan. Usually the more diagnoses, complex treatment, and higher the risk, the higher the reimbursement level the physician will be reimbursed. The E&M Calculator can help calculate the Service Type and Billing Code for you based on what you are documenting in the encounter.Auto-calculates work off of var-tree’s and selections documented for everything. Most providers want the option of free-texting or dictating. It will auto-calculate based on what is filled out as long as the var-tree selections are also coded to be in which specific level section. What the system excludes when trying to auto-calculate is free-text/dictation, but the provider can manually adjust it and mark the specifics in the E&M Calculator section levels.
To use the E&M Calculator, simply expand open the E&M Calculator encounter section by clicking anywhere on its grey title bar, and then click the E&M Calculator hyperlink.
You will then see History Level, Exam Level, and MDM Level fields that have branched open.
You can then branch open each level by clicking the hyperlink on the level name. Clicking on History Level hyperlink will branch open the contents of what History is considered. The specific items that you checkmark signify what you have captured.
You can manually checkmark items in the History Level section and it will then change the drop-down for the History Level indicating the level.
Continue to do this in the Exam Level and MDM Level sections.
Finally, based on what the system has seen or you have checkmarked in the E&M Calculator section, the E&M Calculator will display the Service Type and Billing Code that relates. This helps you determine a billing code.
