Understanding the Default E/M Complexity in Eyefinity EHR

To facilitate medical decision making (MDM) coding recommendations, each diagnosis has been assigned a default level of complexity. You can see these default complexities in the following areas of the iPad app and browser application:

  • 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. The following topics describe how to change the complexity of the diagnosis.

Here's how to edit the complexity within the iPad app:

  1. 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.

  2. Tap the Status tab on the right side of screen.
  3. Tap the Complexity drop-down menu and select the appropriate complexity.

Here's how to edit the complexity within the browser application:

  1. 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.

  2. 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.

  3. Locate the Presenting Problem Complexity radio buttons and select the appropriate complexity and click Save.

Looking at Examples of Complexity

If the idea of Eyefinity EHR assigning default complexities seems unintuitive, it might help to look at some real-life examples.

The following table presents some examples of default complexities; it is not exhaustive. Keep in mind that Eyefinity EHR always defaults to the lowest common complexity, and you may select a higher-level complexity as needed.

Complexity Example Diagnoses
Self-limited or minor Subconjunctival hemorrhage
Acute uncomplicated Conjunctivitis
Chronic stable

Well controlled/stable cataract, glaucoma, or macular degeneration
Chronic Exacerbation

Poorly controlled/worsening glaucoma, cataracts, or macular degeneration
Acute with systemic symptoms

Retinal vasculitis

Herpes ophthalmicus

Finding Additional Information

This section also includes the following topics: