You can access this feature by clicking the Coder button near the top right of the Exam screen. The Exam Coder dialog (Fig. 15) helps you determine the optimal level of insurance billing for an exam performed in My Vision Express. The system will recommend a billing level based on whether the exam is for a ‘New’ or an ‘Established’ patient and certain criteria is met in three specific areas (columns in the coder):

1.   ‘History’: this column includes the elements documented in the ‘HPI’ section of the ‘Complaint’ tab as well as those in the ‘ROS’ and ‘PFSH’ tabs.

2.   ‘Exam’: this includes 13 elements of the physical (PHYS) exam throughout its different tabs and the psychiatric (PS) exam in ‘ROS’.

3.   ‘Medical Decision Making’: this refers to the section with the same name in the ‘Assessment’ tab.

For established patients, the documented elements or exam complexity required for two of the areas above must be met. For new patients, the requirements for all three areas must be met. You can quickly refer and make adjustments to the applicable sections in the exam by clicking one of the buttons in the lower left hand side of the Exam Coder dialog.

The 13 elements of the physical exam that affect the second area are summarized in Table 1 below.

Table 1. Elements (by tab) of the physical exam that affect coding
Entrance tab	Refractive tab	External tab	Internal tab	Ancillary tab
1 Ocular motility: Select a value from the ‘Versions’ drop-down box.	2 Testing visual acuity: Fill in the ‘Unaided Acuities’ section.	3 Enter a tonometry reading. Select whether the following categories are normal (‘NL’) or abnormal (‘AB’) on either eye:    4 Lid                     7 Cornea    5 Pupil                  8 Anterior chamber    6 Conjunctiva      9 Iris	Select whether the following categories are normal (‘NL’) or abnormal (‘AB’) on either eye:    10 Lens    11 Retina    12 Optic disc	13 Gross visual fields:  Select the test performed in the ‘Visual Fields section.

Fig. 15 shows the coder for a sample exam for an ‘Established’ patient. The documented elements for the exam are highlighted in blue. Based on them, the coder recommends that you bill at the 99214 level (highlighted in red) since you meet the requirements for the ‘Exam’ and ‘Medical Decision Making’ columns. It also tells you that your history column meets the requirements (also highlighted in red) for billing at the 99215 level, which you can do for the current (established) patient by either documenting one more element in the ‘Exam’ column or designating the exam as “High Complexity”. You would need to do both if your patient was ‘New’ instead of ‘Established’ and you still wanted to bill at the 99215 level.

Click the Close button when you are done with the Exam Coder dialog.