Coding Compliance Internal Medicine EHR

No more down-coding for fear of inadequate documentation: let PracticeStudio's E/M Coding function do the work for you.

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Check Documentation Anytime

As you document an encounter in a patient's EHR, PracticeStudio records the number of corresponding E/M code bullets (documentation requirements) that are being met.

Choose the E/M coding option to see what documetation level is currently met. Additionally, quickly see what requirements will increase the current encounter to the next documented billing level. Easily access the current E/M levels from the dashboard on the Home Screen or through the Options menu on any screen.

  • Problem Focused
  • Expanded Problem Focused
  • Detailed
  • Comprehensive
Charting
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Charting

History

From the History tab, the user can quickly observe the documented levels and the needed charting to increase the Achieved E/M Level:

  • Chief Complaint
  • History of Present Illness
  • Review of Systems
  • Past, Family, Social History
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Examination

The E/M coding system shows the current Examination with the currently met and necessary requirements. You can even choose the type of examination being performed to narrow the focus of the exam and the calculations.

Charting
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Charting

Complexity of Decision

When documenting the complexity of decision, the E/M coding complexity tab will allow users to easily determine the appropriate level based on the following measures:


  • Number of Diagnosis or Management Options
  • Amount / Complexity of Data to be Reviewed
  • Risk of Significant Complications, Morbidity, Mortality

PracticeStudio makes this normally "gray" process quantifiable by following the guidelines set by CMS to provide data points towards the decision making process. In the past, and in most competitive systems, this is an area that is vague and attracts attention during audits. With PracticeStudio, you can code with confidence when using the Complexity of Decision making as part of the calculated total.

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Suggested Billing

Once the user has successfully documented the appropriate charting measures, the billing tab will provide the user with the suggested billing code based on the documentation that has been provided.

Charting
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