To properly code an encounter from the evaluation and management series (i.e., 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 the components contain elements. The number of elements 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, and Lens. An exam that addresses ALL of the components is weighted more heavily than an exam that addresses five of the components. As always, the number of elements that are addressed is determined by the patient's needs and/or the doctor's professional opinion 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. The auto-coding system is enabled by checking the box for Medical Reason on the RFV screen. See Example
At the conclusion of the encounter on the Coding screen, you will notice two buttons: Code Exam and Auto-Code Preview. As the names suggest, Code Exam counts 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 displays before the code in the Performed Services list. See Example
The Coding Results modal displays 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 by clicking Accept, or click Cancel, and the Coding Results will not be applied. See Example
The Coding Results can serve as a powerful educational tool in developing comfort with the 99xxx series office visit codes.
The most important thing to remember 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 are not using those areas, the system will not 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 are 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.