The Framework and E&M Coder

The Framework for SMARText Documentation

The framework for new generation documentation is incorporated within many of the items in the on-line library of SMARText Items and docuplates.

Learning and incorporating this framework of organization within documentation promises to greatly increase the value of the information within medical records. It is a major step toward turning the typical gobbilty-goop of words (to the computer) into real data that can significantly improve the quality of care, practice efficiency, information access, and practice income.

This section will cover the basics of the framework as well as introducing the E&M Coder. For a detailed description of the structure and logic SOAPware uses to calculate the E&M codes, see

The Framework for SMARText Documentation.

To access the E&M Coder, Click Tools in the menu bar, and Click the E&M Coder menu item.

The E&M Coder consists of three sections - E&M Scoring, Methodology and Exam Types, as shown above.

Evaluation and management codes, as designed by CMS and the AMA, have 5 levels of service (or level of complexity) for each type of patient encounter (new patient, established patient, consultations, initial hospital visit, subsequent hospital visit, ER encounter, etc.).

See - 1997 Documentation Guidelines for Evaluation and Management Services at the CMS web site.

The level of service (or evaluation and management code, E&M code) for encounters is determined by 3 categories: History, Exam and Decision Making.

In order to justify a level of service for any/all levels of service, there must always be chief complaint and at least one diagnosis. Until there is a chief complaint, a warning will be displayed at the top of the E&M Coder.

Specific SMARText items must be incorporated into documentation in order to get assistance in determining the level of service. Docuplates/templates with the SMARText items used within the framework (and E&M coding) can be downloaded from the on-line SOAPware library.

Note: Toggle/Quick Entry SMARText items and the Docuplates that incorporate them are not E&M Coder compatable.

To get started, Open a patient chart, go to the SOAP Notes tab and create a new docutainer by Clicking the New Docutainer/document button with the green +).

Now to download a docuplate containing the framework. Click on Docutainers in the main menu bar, and Click the Docuplates menu item (or Press F6)

1. Type EMC in the search box, then Click the Search button (i.e. magnifier glass) to display a list of some of the docuplates available to download from the online library.

2. Sort the list by Clicking the Description column header.

3. Click a docuplate list item to download. Notice that dates are sometimes added to the end of the description. Select the more recent dates when there is a choice. In the example, Click EMCo.

4. If the docuplate is in the online library  it will have a triangle (poining- down) to the far left. Press the Download button, as shown in above screenshot. Depending on the size of the docuplate, the download could take several seconds to complete. When it has completed successfully, a preview of the docuplate will display on the right of the Docuplates viewer.

This is a typical docuplate that is compatible with the E&M Coder. The lay out and wording of the text can be edited to reflect clinician's preferences.
 

5. Click the Insert button, as shown in the screenshot above. The selected docuplate will now populate the current SOAP encounter note, as shown in the screenshot below. Rarely are all of these headers in a docuplate actually utilized for any single, specific patient encounter. Therefore, after finishing the documentation, any unused items will be removed by right-clicking in the SOAP Note, and Clicking the Remove Unused Items menu item (or Press F9).

History

Most of the history components for E&M coding are placed in the Subjective area of encounter notes. For this demonstration, we have entered a simple E&M Coding Outline docuplate into an empty encounter note.

For the E&M coder to work properly, it is necessary to place certain combinations of SMARText items into the subjective field.

Below Subjective, is a list of the headers for all the subjective SMARText Items that can contribute to the history scoring. When you Click on one of these blue underlined headers in a chart, it brings up a pick list of items for selection.

1. While the SOAP Note is still open, Click Tools in the menu bar, and Click the E&M Coder menu item
2. Next, Click on CHIEF COMPLAINT located below Subjective in the encounter note.

3. Click the (Most Common Chief Complaints) checkbox as shown in the screenshot above. This will open another pick list in the SMARText Quick Access containing the most common chief complaints.
4. Click the checkboxes next to your selection(s).

Notice the E&M Coder message has changed from Please enter a Chief complaint to Please enter a Diagnosis.

The next E&M coding history section is the History of Present Illness (or HPI). In general, again, each time one of these headers is associated with information that follows them (by selecting an item in its pick list or typing into its comments section), then a point is added to the HPI score.

1. For example, Click ONSET/TIMING:, and Click the 3 days ago list item in the SMARText Quick Access list. Notice there is one HPI item and the E&M Coder indicates the Current HPI Point as 1.

The following screenshot shows an HPI score of 9. This may be a little confusing because there are only 8 HPI headers. The SMARText item with the header  SYMPTOMS/RELATED: is a special exception in that it has a unique capability to add up to 3 HPI points, by way of adding 3 separate SMARText items. However, if a 4th item is added, it will still only add 3 points.

In this example, it contains 2 items and so it adds 2 points to the HPI. Hopefully, it will be apparent that the maximal possible HPI score is thus 10. The maximum is reached when all 8 HPI items have associated information, and the last, SYMPTOMS/RELATED: , has at least 3 separate items.

Exam

The exam documentation is entered into the Objective section in SOAPware. There are 14 exam systems listed in the CMS/AMA documentation guidelines:

          

Exam items, generally = 1 point

In the General Multi-Systems Exam as defined by CMS/AMA, there are close to 50 specific exam items that can be addressed. In general, each of any one of these items, included within an exam, will add one point to the total exam score.

According to the E&M documentation guidelines, a level 5 encounter must address no less than 18 (of about 50) exam items in no less than 9 (of 14) different systems. In contrast, a level 4 encounter must address at least 12 exam items in at least 2 different systems.

Once the documentation is completed, any of the physical exam elements in the objective field left blank can be automatically removed. Right-click in the Objective field of the SOAP Note, and Click the Remove Unused Items menu item.

Earlier, the general statement was that one exam item would be equal to adding one point to the exam score. However, the rule of one point per item (that also contains associated information) varies slightly in dealing with 2 issues in the exam:

1- Vital Signs

Vital Signs must include at least 3 of the 7 specified by CMS. These are recorded-entered while working within the Vitals Manager, and then are transferred from the Vitals Chart Section to the SOAP Note for scoring.       Transfer to SOAP Note by Clicking the Transfer button or  Ctrl+Alt+T

 

Decision Making

The Decision Making issues of the CMS documentation guidelines is comprised of 3 subcategories:

1 - Number of Problems/Diagnoses

2 - Data/Studies

3 - Level of Risk

While the first 2 subcategories are a little more specific, the section dealing with level of risk is open to interpretation, and not easily automated. Because the level of risk is very much subjective, there is no good way to accurately automate its value within a computer-based medical record.

As a compromise, the SOAPware coding wizard simply adds one point for each diagnosis listed in the assessment field when it is calculating the subcategory dealing with the level of risk. Therefore, it is extremely important to review the calculated risk score before accepting any suggested level of service.

2 - Data/Studies

For calculating the Data subset of the Decision Making score, the automatic coding wizard will look into the Plan field.

 

Data points are added to the Decision Making score based upon the following formulas:

Plans for New Diagnosis
Lab/Tests	1 point
X-Rays	1 point
Studies (Other than Lab or X-Ray)	1 point
Old Records Requested	1 point
Discuss with physician	1 point
Summary Updated	2 points
Second Interpretation	2 points

 

Data points are added when data is associated with the SMARText Items Types designed for use in the Plan. Each time you Click on a header (blue, underlined text), a Quick Access list will open with items to select which are specific to that header.

In order for the E&M Coder to function properly, it is necessary to include specific SMARText Items designed to function within it. 

Click on Lab/Tests.

Click a Lab item checkbox in the Quick Access list

3. Click on Related Dxs, and another Quick Access list with diagnosis codes will open. Click the diagnosis list item that is associated with current the Lab/Test.
4. Click on  Modifier(s), if applicable, and select from another Quick Access list of modifiers. 

 

3 - Level of Risk.

Determining the third category of Decision Making, the Risk Score, is very difficult to accomplish automatically. Of all the elements of E&M coding, it is the least defined.

The guidelines list several examples of different patient encounters and then assign risk levels rather than delivering any specific rules. Without rules or logic, it is only possible for the software to make guesses. The guessing logic SOAPware E&M Coder uses is simply to add one point for each of the first 4 diagnosis that are listed in Assessment. Obviously, this will rarely reflect the actual level of risk. Before accepting any suggested level of service, you should always check for the appropriate risk score. E&M Coder auto-selects a level of risk that will be labeled be in red…

                                    
Red Text tells the user that the software has guessed. The user should select a level of risk by clicking on the down arrow.

• 1- Minimal =1 point
• 2- Low risk = 2 points
• 3 - Moderate risk =3 points
• 4 - High risk = 4 points

Changing the Level of Risk: by making a selection, causes the text to turn black

Note:  Leaving the encounter (going to another encounter or chart) will cause the E&M Coder to change the Level of Risk text back to Red for unverified.

Path (Intermediate) - Tutorial - Create and use a customized docuplate