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ICANotes Self Codes Using E/M Codes or Psychotherapy Codes
ICANotes self codes using Evaluation / Management code numbers according to HCFA's Guidelines (from Documentation Guidelines for Evaluation and Management Services, November 1997).
HCFA guidelines are so complicated that a computer is a practical necessity. As buttons are pushed, ICANotes records (and you can observe) which history and exam elements are being credited. The level of Medical Decision Making is also scored on the basis of buttons pushed. Finally, ICANotes automatically takes into consideration the site of service (office, hospital, nursing home, etc.) and calculates the highest possible reimbursable code supported by your note.
The page below is always available by pushing the "show me coding" button, and may be consulted to see what elements have been credited by the program; what levels of History, Exam, and MDM have been achieved; and what code is permissible for the site where you are working.
In the example below, ICANotes, on the basis of buttons pushed, credited the Doctor with 5 History elements and an Expanded Problem-Focused review of symptoms. This supports an Expanded Problem Focused History. This, in combination with a Problem-Focused Exam and low complexity Medical Decision Making, supports a code of 99201 when a complete evaluation is performed in an office or other outpatient facility.