To properly code an encounter from the evaluation and management series (those 99xxx office visit codes), three components of an encounter need to be known: the case history, the physical exam, and the medical decision making. Each of those components contains “elements” and the number of those that needed to be addressed during the visit determines the grading of the overall component.
The physical exam component, for example, contains elements like VA, IOP, VF, Cornea, Anterior Chamber, Lens, etc. An exam that addresses ALL of the components is weighted more heavily than an exam that addresses five, for example. As always, the number of those elements that are addressed is determined by the patient and/or doctor's needs on that day and not the desire to code to a higher level.
RevolutionEHR features an auto-coding system that can assist you in determining the proper 99xxx series office visit code for a particular encounter. It’s enabled by checking the “Medical Reason” box on the RFV screen:
At the conclusion of the encounter on the Coding screen, you’ll notice two buttons: “Code Exam” and “Auto-code Preview”. As the names suggest, “Code Exam” will count up the number of elements documented in each of the components within the encounter and then apply the qualifying 99xxx series code to the Performed Services list. You know an encounter has been auto-coded when an “A” appears before the code in the Performed Services list:
“Auto-code preview” will present you with a visible explanation of how the system arrived at the final code prior to applying it to the encounter. From there the code can be applied to the encounter (via “Accept”) or cancelled:
The auto-code preview window can serve as a powerful educational tool in developing comfort with the 99xxx series office visit codes.
Most importantly about the entire auto-coding process: the auto-coding system looks at specific areas within the encounter to count the related elements so if you’re not using those areas, the system won’t be accurate. Within the case history, for example, the HPI is “counted” by reviewing your documentation on the HPI screen. So while the use of that screen is certainly not required from a documentation perspective, if you’re not using it your auto-coding will not be correct.
Ultimately, the auto-coding system works best when used in conjunction with your knowledge of coding.