Index

• Sections
  • To enable E&M Coding
  • Inpatient E&M Coding

To enable E&M Coding

Security Administrators can enable users for auto coding via the Security Center by accessing Settings & Directories.

From Settings & Directories:

a. Click on the Security Center button.

b. Enter your Password

c. Click the 'OK' button

In the Security Center, locate the user to be enabled for auto-coding, and at the far right side of the screen click on the 'Edit' button.

In the Privileges column, click the radio button to set ‘allow auto-code’ to ON, then click to save. 

The following prompt will ask you to confirm enabling the user for auto-coding and the $4.00 monthly fee. If you have any questions about this fee, please contact sales@icanotes.com.

If you would like to enable this function, click on the 'Agree' button outlined in green.

If you would not like to enable this function, click on the 'Cancel' button outlined in red.

Click the Back button to return to the Security Center.

Click the Settings & Directories button to exit the Security Center.

Once saved the user should log out from the pink 'Log Off' button in the Chart Room, then log back into ICANotes.

Inpatient E&M Coding

Auto-coding is based on three main areas within the Progress Note: History, Exam, and Medical Decision Making (MDM).

As you chart a patient’s note using the built-in shrub content, the system will track your content in order to help score a service code at the highest level of reimbursement.

Clinicians may use custom buttons or free-text into the yellow text area in order to complete their note without using the ICANotes shrub content. However, free-texted entries may not trigger the points allotted for that clinical documentation. In that case, the clinician may give themselves credit by clicking on the appropriate button, such as Location, Duration, etc. The clinician is responsible for any points they assign themselves and must ensure they have that information within the note itself.

When finished with your note, go to the service code entry and click the 'Enter' button.

Clicking 'Enter' will open the Service Code window.

a. Click on the 'E&M Code For Me' button and the program will determine the highest reimbursable service code based on the content of your note

b. The code that best fits the documentation will populate.

c. To view the coding matrix, click the 'Show E&M Coding' button 

You can view the Coding Matrix to see what elements are required for scoring. The What Do I Need? section at the right will show you the required scoring elements each for History, Exam, and Medical Decision Making based on the level of service. To the left, you will see which elements the program gave you points for and will calculate a score at the bottom of each column.

You are issued the highest level of coding as long as you meet the basic requirements. In the example below, the patient note needed to meet 2 out of 3 basic requirements in order to meet the 99214 (Office Pt, Established) service code threshold. While History needed a score of 3 but only scored 2, Exam and MDM (Medical Decision Making) both met the required scores of 3 and 2, res