We advise that levels of service be primarily determined by the nature of the visit and not how much documentation can be created. For example, if a patient comes in with a simple rash and no other problems or issues, then that is most likely going to be a level 3 visit, even though it is very easy to have documentation to support a higher level. Let the reason/nature of the visit determine the level you submit.

In order to justify a level of service for any/all levels of service, there must always be a chief complaint and at least one diagnosis. Until there is a Chief Complaint, a warning will be displayed at the top of the EM Coder.

Subsequently, if a diagnosis hasn’t been entered, another warning is displayed.  

Only after there is both a Chief Complaint and at least one diagnosis will E&M Coder begin to suggest levels of service.

Specific SMARText items and docuplate structure must be incorporated into documentation, in order to get assistance in determining level of service.

EM coder compatible docuplates may be found in the Docuplates Menu (F6).

To Search for a EM coder compatible docuplate:

1. Type “EMC” into the search text box, then Click on the search icon
2. Select one of the EMC docuplates
3. Click on the blue download icon to download the docuplate to the local database

The above screenshot shows a typical docuplate that is compatible with the SOAPware EM Coder.  This docuplate can be entered into an encounter note (SOAPNote) to get started with EM Coding.

To insert this docuplate into an encounter, create an empty SOAPnote, then Click on the Insert button.

*Note:  Rarely are all of these headers in the outline utilized within any single, specific patient encounter. Therefore, “Remove Unused Items” automatically removes all the empty headers (the ones you do not address).  Actually, what you are viewing are the SMARText “Headers” for specific types of ST items. These are examples of the types SW uses to calculate the level of service.  Each of these SOAPware headers represents an element defined in the documentation guidelines from CMS.

Clicking on the pick list headers (Click on Chief Complaint(s)) in a chart brings up a pick list of items that will display in the SMARText Quick Access window.

Each header is associated with information (by selecting an item from the associated pick list or  by typing comments using the click-and-type method), which then adds a point to the corresponding section.

As an example:

1. Select  an item from "ONSET/TIMING: Reports occurrence as" (such as 3 days ago)
2. One (1) point is added to the EM Coder HPI score

The EM Coder current points will re-calculate after further documentation has been placed in the Chief Complaint, HPI, and ROS.

To clean up documentation and remove any unused items.

1. Right click in the Subjective field
2. Left click on “Remove Unused Items”.  This will remove any headers left unused.

The PFSH information comes from specific sections of the medical summary.

Specific sections in the summary need to contain data elements in order for the coder to be able to add PSFH points to the score. EM coder checks to see if any of 3 groups of sections within the summary contain any data items.

Past History includes any information within any one of the five sections:

• Active Problems
• Inactive Problems
• Surgeries
• Medications
• Allergies

Any information from the Social History section.  This information may be free text  or SMARText documentation.  

Any information from the Family History Section. This information may be free text or SMARText documentation.

Past Family Social History (PSFH) can add up to 3 points to the history score. One point is added for each of the 3 groups, above, for any data items within them.

Understanding the role of Social History and/or Family History sections is easy because any data in either one adds a point to the history score. So, if both Social History and Family History have any information, a total of 2 points arises

The final encounter documentation, which is either printed or stored, must include at least some information from these “summary” sections to justify any level of service above level 3.  If a level of service above level 3 is selected, the document design utilized to create the final documentation (either printed or stored) will need to include some of these summary sections in addition to the 6 fields in the SOAP encounter notes.