2021 E/M Coding in Eyefinity EHR

Eyefinity EHR is ready to help you comply with the Evaluation and Management (E/M) coding changes that take effect January 1, 2021. Eyefinity EHR simplifies the coding process by suggest billing codes supported by your clinical documentation and based on AMA and CMS requirements. By default, Eyefinity EHR 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.

Eyefinity EHR 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 Eyefinity EHR and read the topics below for more detailed instructions.

You will likely need to update your exam protocols to accommodate the new coding guidelines.

Billing by Medical Decision Making (MDM)

Medical decision making is based on three criteria:

  • Number 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, Eyefinity EHR automatically calculates MDM based on your exam selections. This allows you to document your exams while focusing on patient care rather than the complexities of coding.

  • Each diagnosis and associated diagnosis in Eyefinity EHR has been assigned a default complexity based on AMA guidelines. For more information, go to Understanding the Default E/M Complexity in Eyefinity EHR.
  • Some tests have been assigned a default complexity.
  • Some plans have been assigned a default risk complication, morbidity, and mortality level.

You may quickly review the complexity and assign a more appropriate level as needed. To learn more about the elements that contribute to these levels and their associated CPT codes, refer to Understanding E/M Coding Levels.

Billing by Time

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.

Finding Additional Information

This section also includes the following topics: