Reviewing Coding in the Visit Overview (Web)

Encompass supports the latest Evaluation and Management (E/M) coding requirements. Encompass simplifies the coding process by suggest billing codes supported by your clinical documentation and based on AMA and CMS requirements. By default, Encompass autocodes exams based on medical decision making (MDM); however, you have the ability to review the coding at every step of the way, and you have the option to override the complexity level of the case or override the suggested billing code. You also have the ability to code the visit based on the time spent by clinical staff rather than basing the coding on MDM.

Encompass streamlines the coding process while giving you the ability to exercise your professional judgment. Watch the following videos for an overview of E/M coding in Encompass and read the topics below for more detailed instructions.

What do you want to do?

Medical decision making is based on three criteria:

  • Number and complexity of diagnoses or treatments
  • Amount or complexity of data to be reviewed
  • Risk complications, morbidity, or mortality

You must document at least two of these criteria.

To streamline your workflow, Encompass automatically calculates MDM based on your exam selections. To this end, thorough exam documentation is essential to ensuring you're billing at the highest appropriate level.

  • Document and verify the complexity of all diagnoses and associate diagnoses. Diagnoses contribute to the complexity. Each diagnosis and associated diagnosis in Encompass has been assigned a default complexity based on AMA guidelines. For more information, go to Understanding the Default E/M Complexity in Encompass.
  • Document all tests performed. Tests contribute to the data reviewed. Tests have been assigned a default complexity.
  • Document all medications prescribed and decisions associated with plans. Medications and decisions contribute to the risk of complication. Plans and medications have been assigned a default risk complication, morbidity, and mortality level.
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Scroll down the page until you see the E/M Medical Decision Making Calculation tile on the left side of the page.

You can adjust the complexity of diagnoses and associated diagnoses to ensure that Encompass calculates the estimated E/M code for the visit is accurately.

  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Scroll down to the Impressions and Plans section.
  3. Locate the diagnosis and click the Complexity and Status link.

    The Select Complexity and/or Status window opens.

  4. Click the Presenting Problem Complexity drop-down menu and select a complexity.

    Every diagnosis is assigned a default complexity based on AMA guidelines. Tap the Definitions link to learn more about the complexities.

  5. Select a Status as needed.

    Selecting a Status is optional and does not impact billing.

  6. Click Save.
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Swipe up to the Impressions and Plans section.
  3. Locate the associate diagnosis and click Edit.

    The Associated/Cause Dx window opens.

  4. Click Apply & Edit Complexity.

    The Associated Dx Complexity window opens.

  5. Select a Complexity and click Save.

    Every diagnosis is assigned a default complexity based on AMA guidelines. Tap the Definitions link to learn more about the complexities.

    The associated diagnosis now reflects the complexity you selected.

  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Locate the CC/HPI|ROS section header, click the Add CC/HPI or ROS drop-down, and select Independent Historian.

    The Add Independent Historian window opens.

  3. Click the Who Provided this History for the Patient? drop-down menu and select the appropriate person.
  4. Click the Why was this History Provided by and Independent Historian? and select a reason.
  5. Click Save.

As an alternative to billing based on medical decision making, the code level can be based on physician time for face-to-face, in-office services. Time may include preparing to see the patient; ordering medications, tests, or procedures; and care coordinations, as long as these activities occur on the same day as the visit.

  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Scroll down to locate the Billing section on the left side of the page.
  3. Click Bill by Time.

    The Bill by Time window opens.

  4. Enter the Total Time (minutes).
  5. Click the Time Spent on the Following drop-down menu and select one or more activities.
  6. Click Bill by Time when you’re finished.