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E&M Coding in AHLTA

AHLTA's E&M coding section in the Disposition module utilizes a calculator to assess encounter documentation based on CMS guidelines. Providers can adjust Patient Status, Service Type, and Exam Type to ensure correct E&M coding. Additionally, the Selection tab allows manual E&M code selection and description viewing.

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E&M Coding in AHLTA

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  1. E&M Coding in AHLTA The E&M coding section of AHLTA exists in the Disposition module and defaults to the Calculated E&M. The E&M calculator evaluates structured text documentation in the encounter using Patient Status, Service Type and Exam type to determine an E&M code based on the 1997 CMS coding guidelines.

  2. E&M Coding in AHLTA The provider may alter Patient Status using the drop-down.

  3. E&M Coding in AHLTA The E&M calculator will then re-calculate the encounter E&M based on the new patient status.

  4. E&M Coding in AHLTA Service type and Exam type can also be altered using the drop-downs.

  5. E&M Coding in AHLTA The E&M calculator will then re-calculate the encounter E&M.

  6. E&M Coding in AHLTA A provider must select the “Selection” tab to select an E&M code other that derived by the E&M calculator. Examples of when this process may be needed include, extensive use of free text in the encounter (which the calculator can not account for) and a desire to code the encounter based on the 1995 CMS coding guidelines.

  7. E&M Coding in AHLTA The default E&M category on the Selection tab is Office/Outpatient Visit. E&M codes within that category are displayed in the E&M Codes field.

  8. E&M Coding in AHLTA The E&M code selected by the provider is displayed in the “Selection E&M Code.” A description of the E&M code is provided in the E&M Description field below.

  9. E&M Coding in AHLTA A provide may select a different E&M Category from the drop down.

  10. E&M Coding in AHLTA The E&M Codes for that category are now displayed for selection in the E&M Codes field.

  11. E&M Coding in AHLTA The E&M code selected by the provider is displayed in the “Selection E&M Code.” A description of the E&M code is provided in the E&M Description field below.

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