The exam documentation is entered into the Objective section in SOAPware.  There are 14 exam systems listed in the CMD/AMA documentation guidelines.

Exam Items generally - 1 point.

In the General Multi-Symptoms exam as defined by the CMS/AMA, there are close to 50 specific exam items that can be addressed.  In general, each of anyone of these items included within an exam will add 1 point to the total exam score.

According to the E&M documentation guidelines, a level 5 encounter, must address no less than 18 (of about 50) exam items in no less than 9 (of 14) different systems. In contrast, a level 4 encounter must address at least 12 exam items in at least 2 different systems.

Once the documentation is completed, any of the physical exam elements in the objective field left blank can be automatically removed via the “Remove Unused Items” command in the Objective menu.

Earlier, the general statement was that one exam item would be equal to adding one point to the exam score. However, the rule of one point per item (that also contains associated information) varies slightly in dealing with 2 issues in the exam:

Vital Signs must include at least 5 of the 7 specified by CMS. These are recorded-entered while working within the Vitals manager and then are transferred from the Vitals Section to the encounter for scoring.

At least 2 of the 4 data item types associated with LYMPH: must have associated data in order to add the one point available for lymph.

Another type of exception to the usual flow within exam systems is encountered when dealing with Genitourinary item types. In this case there is an extra step to designate either male or female exam.

Decision-Making section of the CMS documentation guidelines is comprised of 3 subcategories:

• 1 - Number of Problems/Diagnoses
• 2 - Data/Studies
• 3 - Level of Risk

While the first 2 subcategories are a little more specific, the section dealing with level of risk is open to interpretation and not easily automated. Because the level of risk is very much subjective, there is no good way to accurately automate its value within a computer-based medical record. As a compromise, the SOAPware coding wizard simply adds one point for each diagnosis listed in the assessment field when it is calculating the subcategory dealing with the level of risk. Therefore, it is extremely important to review the calculated risk score before accepting any suggested level of service.

To allow the necessary sub-items in the Structured Dx to be automatically  placed in the chart and perform EM coding, go to Tools> Options>Structured Dx, and place checks in the boxes in front of :

1. Plan
2. Course
3. Initial Date

For calculating Number of Problems/Diagnosis score, the SOAPware automatic coding wizard will look at each of the lines in the Assessment field…if the line contains a diagnosis and if it also includes the encounter date (i.e. this is to indicate a new diagnosis), and if there are specific instructions given such as “(See Plan)”, and if it includes “uncontrolled” or “worsening” in course, then 4 points are added to the Decision Making score.  

There is no maximum point total here with this rule, so if 3 lines meet these criteria, then 12 points are added to the point total. For example, if 3 similar diagnosis ST items (and sub-items) placed into the objective field, then 12 points are added to the score.

For calculating the Data subset of the Decision Making score, the automatic coding wizard will look into the plan field. In order for the E&M coder to function properly, it is necessary to include specific ST item types designed to be recognized as addressing data, studies, etc. This is an example of the list of headers that are displayed by a set of specialized ST items designed to function within the EM Coder.

Data points are added to the Decision Making score based upon the following formulas:

• Lab/Tests: 1 point
• X-rays: 1 point
• Studies(other than lab or x-ray): 1 point
• Old Records Requested: 1 point
• Discuss with physician: 1 point
• Summary updated: 2 points
• Second Interpretation: 2 points

Data points are only added when data is associated with the pick lists above by either selecting an item from the pick list, or inserting the correct SMARText items.

Data points are added when data is associated with the ST items types designed for use in the Plan. For example, if “Lab/Tests:”is changed to“Lab/Tests: CBC” then 1 point is added to the Data subset of the Decision Making score.

Plans for New Diagnosis: - This would be where you would place plan items for any new diagnosis that have been placed into the Assessment field (i.e. those which have the date added and the text “(See Plan)” as below:

Assessment

• Diabetes mellitus type II

Plan

• Plans for New Diagnosis: Diet - Dietary consultation for 1800 cal ADA diet.
• Lab/Tests: This line is where you would place documentation for planned laboratory studies or testing. For example…
• Lab/Tests: 85025 - LAB, CBC-complete.…adds 1 point.
• X-rays:  This line is where you would place documentation for radiographic items. For example…
• X-rays: 71020 - X-Ray, Chest, 2 views, AP/lateral. …adds 1 point.
• Studies(other than lab or x-ray): This line is where you would place documentation for other types of studies other than labs or x-rays. For example…
• Studies(other than lab or x-ray):93010 - EKG, Interpretation only. … adds 1 point.
• Old Records Requested:  This line is where you would place documentation of the fact that outside medical records are being obtained. For example…
• Old Records Requested:Record Release obtained requesting old records from the hospital.…adds 1 point.
• Discuss with physician:  This line is where you would place documentation of the fact that you consulted or discussed with another physician. For example…
• Discuss with physician: Neurologist, Dr. Davis regarding need for MRI of head.…adds 1 point.
• Summary updated: This line is where you would place documentation of the fact that you have updated information within the medical history which in SOAPware would be the fields on the Summary side. For example…
• Summary updated:The summary record was updated with pertinent information from previous records (10-20 minutes).…adds 2 points.
• Second Interpretation:  This line is where you would place documentation of the fact that you have rendered a second opinion. For example…
• Second Interpretation:The previous treatments were reviewed and an assessment given. …adds 2 points.

These 8 elements determine the score for the “Data” portion of the Decision Making section. Any elements left blank are automatically removed by selecting the “Remove Unused Items” in the Plan menu.

Determining the third category of Decision Making, the Risk Score, is very difficult to accomplish automatically. Of all the elements of EM coding, it is the least defined. The guidelines list several examples of different patient encounters and then assign risk levels rather than delivering any specific rules. Without rules or logic, it is only possible for the software to make guesses. The “guessing” logic SOAPware E&M coder uses is simply to add one point for each of the first 4 diagnoses that are listed in Assessment. Obviously, this will rarely reflect the actual level of risk. Before accepting any suggested level of service, you should always check for the appropriate risk score. EM Coder auto selects a level of risk that will be labeled be in red…

This tells the user that the machine has selected it for them.The user should select a level of risk by clicking on the down arrow.

• 1 - Minimal =1 point
• 2 - Low risk =2 points
• 3 - Moderate risk =3 points
• 4 - High risk =4 points

This table, provided by CMS, demonstrates some examples as to how to determine the risk level.

Changing the Level of Risk: by making a selection causes the text to turn black

Note, leaving the encounter (going to another encounter or chart) causes the EM Coder to change the “Level of Risk” label back to red or unverified.