Understanding the Default E/M Complexity in Eyefinity EHR on the iPad
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, tap the Diagnoses tab on the left side of the screen and select the diagnosis.
OR
If the diagnosis has been recorded, tap the Quick Impression Edit tab at the bottom of the screen and tap Resume Dx.
- Tap the Status tab on the right side of screen.
- Tap the Complexity drop-down menu and select the appropriate complexity.
| Complexity | Example Diagnoses |
|---|---|
| Self-limited or minor | Subconjunctival hemorrhage |
| Acute uncomplicated | Conjunctivitis |
| Chronic stable | |
| Chronic Exacerbation | |
| Acute with systemic symptoms |