Determining final evaluation and management codes (E/M) for 992xx office visits can be based on either of the following:
- Medical decision making.
- Total professional time.
RevolutionEHR provides two tools that help the provider determine which E/M code to use for the encounter.
- An encounter timer (Instructions below).
- Auto-coding (See Evaluation and Management Coding - Auto-Coding).
When the total professional time has been used to determine the final E/M code, the system can include a time stamp on the encounter PDF. See Evaluation and Management Coding - Encounter Time Stamp.
Instructions
User Roles
- Access Admin > Employee/Roles > User Roles.
- Open a User Role.
- In the Access Permissions section, click the arrow next to Patient Module to expand the options.
- Click the box for either/both "View Encounter Timer and Total," and/or, "Manage Encounter Timer and Total." Note: Technicians, Ophthalmologists, and Optometrists have these permissions checked as the default setting.
- Click 'Save.'
- Log out and log in to see the changes associated to the setting.
Practice Preference
- The default setting for this feature is set to "yes," thus, these instructions are if the default has been changed and your practice would like the timer enabled.
- Access Admin > General > Practice Preferences > Additional Preferences > Patients > Encounters.
- Set "View Encounter Timer and Total" to "Yes."
- Click 'Save.'
- Log out and log in to see the changes associated to the setting.
Encounter
The timer displays within the encounter header as hours and minutes (hh:mm). The time indicated on the left is the session timer and represents the time that has elapsed since the timer was started in the employee's current session. The time indicated on the right (Total) is the aggregate of all session timers. See Example
- The timer displays within encounters dated from January 1, 2021 and going forward.
- Click the green arrow to start the timer. See Example
- Click the red square to stop the timer. See Example
- The timer stops and does not automatically restart in the following situations:
- The encounter is closed.
- The patient file is closed.
- Encounter is signed.
- Lock the system.
- Log out of the system.
- When the timer is stopped, either manually or automatically by the system, in one of the above examples, it must be restarted manually.
- To manually update the total time, click the aggregate time beside Total. See Example
- In the Adjust Total Time modal, update the Minutes field with the minutes that need to be added to the existing time. Note: Reason is an optional field. Information from this field is displayed in the audit log.
- Click 'Save.'
- If the timer was running, it will stop and start again automatically.