How to Review Knowtex E&M Codes
Last updated August 7, 2025
How to Use E&M Codes
Overview
The E&M (Evaluation and Management) Codes feature helps you select the appropriate level of service for patient visits based on clinical complexity and encounter time. The system provides intelligent recommendations while allowing you to make the final determination.
Getting Started
Visit Type Detection
The system automatically determines your visit type:
- Consultation: For new patients or when patient type is not specified
- Follow Up: For established patients returning for continued care
Time Entry
1. Locate the "Total Encounter Time" field in the upper right 2. Enter the total time spent with the patient in minutes 3. This includes face-to-face time, review of records, and documentation time
Selecting E&M Levels
Step 1: Choose Your Initial Level
Select from the available service levels:
- Level 2: Lower complexity visits
- Level 3: Moderate complexity visits
- Level 4: Moderately high complexity visits
- Level 5: High complexity visits
Click the numbered button (2, 3, 4, or 5) that best represents the complexity of your encounter.
Step 2: System Recommendation
The system analyzes your clinical note content and provides a recommended level based on:
- Medical decision making complexity
- Clinical documentation elements
- Standard E&M coding guidelines
Step 3: Final Selection Process
If you select the recommended level:
- Your selection is automatically finalized
- No additional steps required
- The level is locked in for billing
If you select a different level:
- A secondary review panel appears
- You'll see the system's recommendation with rationale
- You must provide justification for your different selection
- Complete the rationale to finalize your choice
Understanding Recommendations
How the System Works
The AI analyzes your clinical note for:
- Problem complexity: Number and severity of conditions addressed
- Data reviewed: Lab results, imaging, records reviewed
- Risk level: Management options and potential complications
- Decision making: Treatment plans and follow-up requirements
Recommendation Display
When a different level is selected, you'll see:
- Knowtex Recommended Level: The AI's suggested level
- Your Selected Level: Your chosen level
- Rationale Requirement: Text field to explain your reasoning
Providing Rationale
When Required
You must provide rationale when:
- Your selection differs from the system recommendation
- You choose a higher or lower complexity level than suggested
Best Practices for Rationale
- Be specific: Reference particular clinical elements
- Cite complexity factors: Mention specific decision-making elements
- Document time factors: Note if time-based coding applies
- Reference guidelines: Mention relevant E&M coding criteria
Example Rationales
- *"Patient presented with multiple comorbidities requiring extensive review of systems and complex medication management decisions"*
- *"Time-based coding applied - 45 minutes spent in counseling regarding treatment options and prognosis"*
- *"Straightforward follow-up with stable chronic conditions, minimal decision making required"*
Key Features
Intelligent Analysis
- Real-time Processing: Analyzes your note as you document
- Medical Complexity Recognition: Understands clinical terminology and complexity indicators
- Coding Compliance: Follows current E&M coding guidelines
User Control
- Override Capability: Always allows provider final decision
- Rationale Documentation: Ensures proper justification for coding decisions
- Audit Trail: Maintains record of selections and reasoning
Time Integration
- Encounter Time Tracking: Records total time spent
- Time-based Coding Support: Considers time as a factor in level selection
- Documentation Requirements: Helps ensure proper time documentation
Tips for Accurate Coding
Documentation Best Practices
1. Be Thorough: Include all relevant clinical elements in your note 2. Use Specific Terms: Medical terminology helps the AI understand complexity 3. Document Decision Making: Clearly outline your clinical reasoning 4. Record Time Accurately: Include all time spent on the encounter
Common Scenarios
- Multiple Problems: Higher levels for patients with several active issues
- Extensive Review: Document when reviewing multiple records or test results
- Complex Decisions: Note when treatment decisions involve significant risk or complexity
- Counseling Time: Record when significant time is spent in patient education
Troubleshooting
System Not Providing Recommendations?
- Ensure your clinical note contains sufficient medical content
- Check that you've documented clinical decision making
- Verify the note includes assessment and plan sections
Recommendation Seems Incorrect?
- Review the specific elements the system identified
- Consider if additional documentation would support your preferred level
- Use the rationale field to explain your clinical reasoning
Time Field Issues?
- Enter time in minutes only (no units needed)
- Ensure the field is not locked (check if note status is "Locked")
- Round to whole minutes for simplicity
Compliance and Billing
Documentation Requirements
- Medical Necessity: Ensure services are medically necessary
- Supporting Documentation: Clinical note must support selected level
- Time Documentation: When using time-based coding, document counseling/coordination details
Audit Considerations
- Rationale Preservation: Your explanations are saved for audit purposes
- Consistency: Ensure coding aligns with documented clinical complexity
- Guidelines Adherence: Follow current CMS and specialty society guidelines
Benefits
- Improved Accuracy: AI assistance reduces coding errors
- Time Savings: Automated analysis speeds up the coding process
- Compliance Support: Built-in guidelines help ensure proper coding
- Audit Protection: Documented rationale supports coding decisions
- Educational Value: Learn from AI recommendations to improve future coding