E&M Coding

To enable E&M Coding:  

 

Security Administrators can enable users for auto coding via the Security Center by accessing Settings & Directories.

 

From Settings & Directories:

1. Click on the Security Center button.
   
2. Enter your Password
   
3. Click the 'OK' button
   

 

 

In the Security Center, locate the user to be enabled for auto-coding, and at the far right side of the screen click on the 'Edit' button.

 

In the Privileges column, click the radio button to set ‘allow auto-code’ to ON, then click to save. 

 

 

 

The following prompt will ask you to confirm enabling the user for auto-coding and the $4.00 monthly fee. If you have any questions about this fee, please contact sales@icanotes.com.

 

If you would like to enable this function, click on the 'Agree' button outlined in green.

If you would not like to enable this function, click on the 'Cancel' button outlined in red.

Click the Back button to return to the Security Center.

 

  

 

Click the Settings & Directories button to exit the Security Center.

 

Once saved the user should log out from the pink 'Log Off' button in the Chart Room, then log back into ICANotes.

 

 

Inpatient E&M Coding

 

Auto-coding is based on three main areas within the Progress Note: History, Exam, and Medical Decision Making (MDM).

 

As you chart a patient’s note using the built-in shrub content, the system will track your content in order to help score a service code at the highest level of reimbursement.

 

 

Clinicians may use custom buttons or free-text into the yellow text area in order to complete their note without using the ICANotes shrub content. However, free-texted entries may not trigger the points allotted for that clinical documentation. In that case, the clinician may give themselves credit by clicking on the appropriate button, such as Location, Duration, etc. The clinician is responsible for any points they assign themselves and must ensure they have that information within the note itself.

 

When finished with your note, go to the service code entry and click the 'Enter' button.

 

 

 

Clicking 'Enter' will open the Service Code window.

 

 

1. Click on the 'E&M Code For Me' button and the program will determine the highest reimbursable service code based on the content of your note
   
2. The code that best fits the documentation will populate.
   
3. To view the coding matrix, click the 'Show E&M Coding' button 
   

 

You can view the Coding Matrix to see what elements are required for scoring. The What Do I Need? section at the right will show you the required scoring elements each for History, Exam, and Medical Decision Making based on the level of service. To the left, you will see which elements the program gave you points for and will calculate a score at the bottom of each column.

 

 

You are issued the highest level of coding as long as you meet the basic requirements. In the example below, the patient note needed to meet 2 out of 3 basic requirements in order to meet the 99214 (Office Pt, Established) service code threshold. While History needed a score of 3 but only scored 2, Exam and MDM (Medical Decision Making) both met the required scores of 3 and 2, respectively.

 

If you’ve made manual corrections to the coding matrix by self-scoring your note’s content, click the 'Re-Calculate' button and the system will re-calculate the service code score.

 

 

2021 Outpatient E&M Coding Updates

 

For information on the guidelines for E&M Coding please visit this link to view a PDF released by the AMA and read the blue highlighted text closely.  There is a grid on pages 11-14 that covers the elements of E&M Coding.

 

The brief video below will take you through using 2021 E&M Coding.

Video Link: https://youtu.be/1OKCYeQUgIk

 

 

The MDM and Total Minutes Spent fields will dictate your scoring on the new coding Matrix for outpatient facilities. Clinical Status/Complexity is now accessed within the MDM or Medical Decision Making Button. 

  

Additionally, you will find a new Total Minutes Spent field on the Finish Initial and PN Part 2 tabs of these notes.

 

   

 

 

The What Do I Need? section at the right will show you the required scoring elements each for Problems, Analysis, Risk, and Total Time Spent based on the level of service. To the left, you will see which elements the program gave you points for and will calculate a score at the bottom of each column.

 

 

Please note that if you make updates in the work areas using MDM button, you can choose the 'Re-calculate' option to get an updated code!

 

To view more detailed information about the codes used, click on any of the Information icons to see a popover.

 

 

 

 

FAQ and Troubleshooting Tips:

 

What if I'm not getting the Code I was expecting/want to use? 

 

Auto-coding is based on four main areas within the Progress Note: History, Exam, Time Spent and Medical Decision Making (MDM).

 

 

Are there additional codes I can use? 

 

Yes! A Prolonged Service code and the corresponding number of units will populate when the total time for Complete/Initial Assessment is in excess of 75 minutes or a Progress Note is in excess of 55 minutes.

1. The units are measured in 15 minute increments, with each 15 minutes over the stated time being one unit.
   
2. For patients with Medicare as Primary, the add on code will be G2212.
   
3. For all other payers, the add on code will be 99417.
   
4. Prolonged Service code 99417 can only be used with 99205 and 99215.
   
5. These codes will need to be added to your Billing Rates to populate as expected. 
   

 

 

What if I’m not scoring at the right service level? 

 

The Site Location of your note is an important factor to consider. If your Site Type is set to Office/Outpatient service, your service code will calculate at the outpatient level. Make sure your Working At site location is set accordingly from the Chart Room before creating your note.

 

 

What if I'm not seeing the MDM button for outpatient E&M Coding?

 

Check your Site Type and discipline: E&M Coding requires a Prescriber Discipline and an Office / Outpatient Service Site Type. 

The new interface is visible in the Prescriber Progress Note (for all users) and the History of Present Illness tab of a Complete Evaluation for Prescribing user disciplines.

 

Note: Prescribing user types include Psychiatrist, PCP/OBGYN, Nurse Practitioner, Physician Assistant, Physician, and Scribe. Non-prescribing users are not eligible for E/M Code For Me.

 

This site type will not populate the updated E&M Coding. If this is the Site Type listed for your location, you will need to update it.

 

 

To make a change to this information, access the Settings & Directories:

​

1. Click on the blue tab for Group Level Settings & Directories.
   
2. Click on the Sites/Letterheads subtab.
   
3. Click to select the site you want to modify.
   

   

Once you have the site selected:

​

1. Click the 'Edit' button to make changes.
   
2. Click on the drop down menu and select the updated Site Type.
   
3. Click the 'Save' button.
   

 

  

The updated Site Type will be displayed in the Site Listing on the left and on the Facility Info subtab.

 

 

To verify your Discipline, check in Settings & Directories. You must have a Prescribing Discipline to access the updated E&M Coding.

 

   

A security administrator can update the Discipline for any user in the Security Center. 

 

From Settings& Directories:

​

1. Click on the Security Center button.
   
2. Enter your Password
   
3. Click the 'OK' button
   

 

 

Locate the user to update and click the Edit Button.

 

 

Update the user's Discipline.

​

1. Click the Discipline field to populate the list of available Disciplines then select the prescribing discipline you would like to to assign.
   
2. Click the green Save button.
   
3. Click the Back button to return to the Security Center.
   

 

 

 

Click Settings & Directories to exist the Security Center.

 

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