E&M Guidelines

ChartMaker® Clinical offers an E&M coding guidelines tool to assist with CPT-4 code selection after an exam has been completed. This is designed to assist with code selection and is not meant to be the sole factor when deciding on CPT-4 correct coding of an exam.

When your chart note is complete, click Note > E&M Items to bring up a more detailed view of the coding area. The following describes the areas of the E&M dialog:

• The Dx area will show the current diagnoses from the chart note and the Face Sheet Problem/Diagnosis area.

• The Amount & Complexity of Data is where the examiner will choose elements in this box as they pertain to the exam.

• The HPI are will highlight areas that have been selected in the exam and allow you to select additional items as needed.

• The ROS area will highlight areas that have been selected in the exam and allow you to select additional items as needed.

• The EXAM area will highlight areas that have been selected in the exam and allow you to select additional items as needed.
  
  

• The PFSH field allows the examiner to  choose the type of history this exam contains.
  
  

• The Contributing Factors field allows the examiner to choose one item from the Presenting problems, Diagnostic Orders, or the Management Options sections. The following figures below detail these options.
  
  
  
  
  
  

• The Type of Exam area allows the examiner to choose the type of visit this exam represents.
  
  

As areas of the E & M chart are chosen, the Type of Exam section will fill in from left to right to indicate the number of items that have been fulfilled with this exam. The reset button will remove all selected items.

Please note that examiners should only choose items already detailed in the note. Selecting an item in the E & M chart will not change data on the exam and will not include that information in the exam.