Understanding the Default E/M Complexity in Eyefinity EHR
The number and complexity of problems addressed is one of three medical decision making (MDM) elements. To facilitate MDM coding recommendations, each diagnosis has been assigned a default level of complexity. You can see these default complexities in the following areas of Eyefinity EHR:
- E/M Expert within the ocular exam
- Visit overview
- Encounter PDF
In cases where a problem may present at different levels of complexity (i.e., minor, acute uncomplicated, stable chronic), the default complexity is set to the lowest common complexity. Eyefinity EHR defaults to the lowest common complexity to reduce the likelihood of accidentally upcoding the exam.
Editing the Complexity
If you determine the suggested complexity does not meet the clinical condition of the patient, you can adjust the complexity at the time of diagnosis. Here's how:
- In the ocular exam, locate the Diagnoses pane on the left side of the page and select the diagnosis.
OR
If the diagnosis has been recorded, scroll down the page until you locate the diagnosis and click Resume Dx.
- Click the Status button, located near the bottom of the Diagnoses pane.
The Status button displays the name of the default or user-selected complexity, so the button will display as "Stable Chronic Illness," "Self-limited or Minor," or another complexity level.
The Select Complexity and/or Status page displays.
- Locate the Presenting Problem Complexity radio buttons and select the appropriate complexity and click Save.
| Complexity | Example Diagnoses |
|---|---|
| Self-limited or minor | Subconjunctival hemorrhage |
| Acute uncomplicated | Conjunctivitis |
| Chronic stable | |
| Chronic Exacerbation | |
| Acute with systemic symptoms |