Assisted Coding User Guide for

IntelleChartPro
 Assisted Coding User Guide for IntelleChartPro

Table of Contents
Determining the default exam code by encounter type and exam type ...............................................2
My Settings -> My Settings ....................................................................................................................... 2
History Section...................................................................................................................................4
HPI ............................................................................................................................................................. 4
PSFH/ROS Section ..............................................................................................................................5
PSFH .......................................................................................................................................................... 5
ROS ............................................................................................................................................................ 6
V & P Section .....................................................................................................................................7
Exam Section .....................................................................................................................................7
Exam.......................................................................................................................................................... 7
Mental Status ............................................................................................................................................ 9
V&P ........................................................................................................................................................... 9
Medical Decision Making (MDM)...................................................................................................... 10
Coding Section ................................................................................................................................. 10
Coding ..................................................................................................................................................... 10
Appendix A ...................................................................................................................................... 15
E/M vs General Ophthalmological Services comparison ........................................................................ 15

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 Assisted Coding User Guide for IntelleChartPro

To help IntelleChartPro clients determine if they meet a certain level for billing, an Assisted Coding tool
has been implemented. This user guide will walk through how the Assisted Coding tool will work. This
tool is meant to provide a suggested exam level for coding; the provider/biller has the final
determination of the code to be used. See Appendix A for a comparison of E/M vs general
ophthalmological services.

Determining the default exam code by encounter type and exam type
My Settings -> My Settings
Each provider will be able to determine the default exam code to include in Coding, based on the
encounter and exam type. This will help the provider by having one less click to do if the same code is
used the majority of the time for that exam type. The provider can set these default values by going to
the Admin -> My Settings -> My Settings -> Default Codes. This must be done under the provider’s login.

Click on the drop down for each Encounter Type and choose the Default Code to use. The encounter
types listed may be different since they are practice specific.

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Click “Update” to save the changes. A default code is not required for all exam types.

To remove a default code, click “Remove Default” and click “Update” to save the changes.

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History Section
HPI
In the History section, only the HPI elements count toward the billing level for the exam code.
IntelleChartPro will keep a total count of all the approved HPI values selected. Even though the CC does
not count as an element, it is required to be entered for the other elements to be counted.

The CC will have a red left border if a Chief Complaint description is not entered. The values that count
will have a green left border.

Chief Complaint is required to be documented, but does not count as an element, for the items in this
section to be counted. If a Chief Complaint is not selected, there will not be a number indicated on the
History header and the other elements will not be in green.

Once an element is selected and added to the summary row, the element’s bubble will have a green
border. If there are two HPI findings with the same category, such as Duration or Associated Symptoms,
only the first one will count and be highlighted in green. If the first one that was highlighted in green is
removed, the related finding that was not highlighted will become highlighted with a green border. If a
default exam code is set in the admin section, you will see how many elements were selected followed
by how many elements were necessary to meet the selected exam level.

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If a default exam code is not set in the admin section, you will only see how many elements were
selected.

PSFH/ROS Section
PSFH
In the PSFH section, the maximum element count is three. The count is obtained from: at least one
element in either Medical Hx or Surgical Hx; at least one element in Family Hx; at least one element in
Social Hx.

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ROS
In the ROS section, the maximum elements that count is ten; however, more than ten can be selected.
The values that count will have a green left border.

Once an element is selected and added to the summary row, the element’s bubble will have a green
border. If there are two ROS values with the same category, only the first one will count and be
highlighted in green. If the first one that was highlighted in green is removed, the related ROS that was
not highlighted will become highlighted with a green border. On the PFSH/ROS header, counts will show
how many elements were selected followed by how many elements were necessary to meet the
selected exam level.

If the selected exam code does not require elements in PSFH or ROS or an exam code is not selected in
the Coding section, only the number of elements selected will show in the PSFH/ROS header.

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V & P Section
In the V&P section, there are some sections that need to be completed depending on the selected exam
code and relate to items in the Exam section. These are Visual Acuity, IOP and Dilation. A red circle will
appear before the section name if it requires a value and none is entered to meet the selected exam
level.

Exam Section
Exam
The Exam section can have a maximum of 13 elements. The count is made up of:

• Mental Status Exam (in HPI)

• Visual Acuity (in V&P)
• IOP (in V&P)
• Pupils and/or Iris (External/Anterior)
• Motility (External)
• CVF (External)
• Adnexa (External)
o If an Adnexa exam is needed, either Adnexa or L/C/S will count; both Adnexa and L/C/S
can count towards the exam elements
• L/C/S (Anterior)
• Cornea (Anterior)
• A/C (Anterior)
• Lens (Anterior)
• Nerve (Posterior)
• Vessels (Posterior)

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o Must also have either Macula or Periphery for the same eye

On the Exam header, counts will show how many elements were selected followed by how many
elements were necessary to meet the selected exam level.

If the selected exam code does not require elements in PSFH or ROS or an exam code is not selected in
the Coding section, only the number of elements selected will show in the PSFH/ROS header.

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Mental Status
While Mental Status is not part of the Exam section, it will be counted in the Exam Section.

V&P
While V&P is not part of the Exam section, it has a couple of areas that are tied to the Exam section for
the counts. There is a maximum of two items that will be added to the Exam section count if completed:
Visual Acuity and IOP.

Visual Acuity will count as long as one of the rows is populated (OD, OS, OU); text in “Other” will not
count.

IOP will count as long as there is at least one row having a value in either OD or OS.

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Medical Decision Making (MDM)

IntelleChartPro does not account for medical decision making. MDM is at the discretion of the provider.

Coding Section
Coding
The Coding section is where all the above information comes to fruition. The Assisted Coding tool will
help the user to select the appropriate code, or indicate the sections that still need to be completed in
order to properly document the code being selected. This will only apply to the Eye and E/M codes.

NOTE: If a provider has set up default exam codes, that code will automatically be populated in
the Coding section. It is not determined by the assisted coding tool, but the tool will indicate if
the defaulted exam code has met the requirements based on items performed in the chart.
IntelleChartPro will not prevent a user from selecting and using any of the exam codes. The
Assisted Coding tool is just a guide to assist in determining the best code based on key elements
added to the patient’s chart.

Assisted Coding is only applicable when the category is Exam, and is not for a Surgery or Post Op exam
type. A calculator icon will appear to the left of the code dropdown, which will open a new window to
show all the available codes based on the selected Exam type.

There is a tab for Eye and for E/M codes. At a glance, the user will be able to see which sections did and
did not get completed to support each code. MDM will be listed as “User Determined”.

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The user can then click on each code to open up a more in-depth view of each section in the chart. The
expansion will show the two sections (History and Exam) and will highlight in red any areas that need to
be attended to.

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The user will be able to click on the name for each of these items and will be taken to the respective
section in the chart to quickly make updates. This is especially helpful for those items with a red x.

A warning icon will appear to the right of the exam dropdown when a user selects a code that did not
fully meet the requirements. This will further indicate that they should look at this to properly document
the chart to protect themselves in a potential audit.

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Additionally, the three sections will be shown to the right of the warning icon to quickly indicate which
section(s) still needs documentation to use the exam level selected; if a section is not displayed, it has
met the requirements. Clicking on any of the sections will take the user to that section in the chart to
quickly make updates.

Clicking on the warning icon will open a popup that will show the two sections (History and Exam) and
will highlight in red any areas that need to be attended to meet the requirements for the selected exam
code.

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The user will be able to click on the name for each of these items and will be taken to the respective
section in the chart to quickly make updates.

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Appendix A
E/M vs General Ophthalmological Services comparison

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