Practical E/M Audit Form: Established Outpatient Visit (p.1)

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Patient: Name: _________________ Chart #: _______ Date of visit: ___/___/____ Reviewer: ___________________ Date of review: ___/___/____

Select the level corresponding to lowest of the components Level of History

PFSH HPI

5 2 elements Comprehensive

Related 4 1 element >3 chronic conds Detailed

E/M level: 3 0 elements Expanded

2 or no chronology Prob focused

1



Level based on documented "update" of PFSH /ROS no history

Chronology



Fails to document or clearly reflect a chief complaint

Duration



Fails to document supplemental details of positive findings for PFSH

Timing



Fails to document supplemental details of positive findings for ROS

Severity



 Fails to document chronological details of HPI (performing only an "extended" Chief Complaint)

Location



Fails to document the STATUS of at least 3 chronic or inactive conditions

Quality



    *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed

Context



 Copy forward functionality  Copy-paste of pre-loaded generic text Mod. factors



 Documentation by exception, automated or single click

Assoc signs & Sx



 Non-specific documentation resulting from use of pick lists

Select the level corresponding to guideline description Level of Exam multi-system specialty Ophth & Psych

5 2 in each of 9 all major,1 ea minor all major,1 ea minor Comprehensive

Related 4 12 elements 12 elements 9 elements Detailed

E/M level: 3 6-11 elements 6-11 elements 6-8 elements Expanded

2 1-5 elements 1-5 elements 1-5 elements Prob focused

1

 

Fails to document specific abnormal findings no exam 



Fails to document relevant negative findings of symptomatic organ systems

  

 *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed

 

 Copy forward functionality  Copy-paste of pre-loaded generic text 



 Documentation by exception, automated or single click 



 Non-specific documentation resulting from use of pick lists

Select the level corresponding to guideline description Level of Exam 5 8 organ systems or complete single organ system exam Comprehensive Related 4 Extended exam of affected & related areas/systems Detailed E/M level: 3 Limited exam of affected & related areas/systems Expanded

2 Limited exam of affected body area or organ system Prob focused 1

 

Fails to document specific abnormal findings no exam 



Fails to document relevant negative findings of symptomatic organ systems

 *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed

 

 Copy forward functionality  Copy-paste of pre-loaded generic text 



 Documentation by exception, automated or single click 



 Non-specific documentation resulting from use of pick lists

Note: Draw a line through all the levels of care and NPP to indicate the E/M code level submitted (note: level 1 appropriate when care provided under physician's supervision without physician present)

Physical Exam Review (1995 Guidelines) 0 system

1 system 2-9 syst

1-3 elements ROS

Practical E/M Audit Form: Established Outpatient Visit (p.1)

Medical History Review

Physical Exam Review (1997 Guidelines) 4-8 elements / 10 or more

no HPI

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Section 1: Medical History

HPI: see color sheet for listing of chronologic description & 8 elements of HPI PFHS: record which elements have documented inquiries & responses

(see color sheet for documentation of qualitative factors & EHR data entry issues)









Past medical history









Family history









Social history









or UPDATE of PFSH from documented previous visit (assess # elements previously) Number of elements documented ______

ROS: record which organ systems have documented inquiries & responses

(see color sheet for documentation of qualitative factors & EHR data entry issues)









Constitutional









Gastrointestinal









Neurological









Eyes









Genitourinary









Psychiatric









Ears, nose, & throat









Musculoskeletal









Endocrine









Cardiovascular









Integumentary









Hematologic/lymphatic









Respiratory (skin and/or breast)









Allergic/immunologic









or UPDATE of ROS from documented previous visit (assess # elements previously) Number of organ systems documented ______

Section 2: Physical Examination 1997 Documentation Guidelines:

Types of Examinations:









General multi-system exam









Genitourinary (female)









Neurological









Cardiovascular









Genitourinary (male)









Psychiatric









Ears, nose, & throat









Hematologic/lymphatic/immunologic









Respiratory









Eyes









Musculoskeletal









Skin

see exam details in "Documentation Guidelines for Evaluation & Management Coding" 1995 Documentation Guidelines:

Body areas:









Head and face









Abdomen









Back, including spine









Neck









Genitalia, groin, buttocks









Each extremity









Chest, incl. breasts & axillae Organ systems:









Constitutional









Respiratory









Skin









Eyes









Gastroinstestinal









Neurological









Ears, nose, mouth, throat









Genitourinary









Psychiatric









Cardiovascular









Musculoskeletal









Hematol/lymph/immunol Documentation Details:









All other symptomatic or related organ systems documented









All other symptomatic or related organ systems NOT documented









LIMITED examination of (all) affected and symptomatic/related organ systems







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Patient: Name: _______________ Chart #: _________ Date of visit: ___/___/____

Select the 2nd lowest of the RED circled levels Level of MDM Dx or Rx Options Data reviewed & ordered Levels of Risk

5 ext 4 ext 4 ext 4 ext ext 4 ext high high high High

Related 4 mult 3 mult 3 mod3 mod mod 3 mod mod mod mod Mod

E/M level: 3 lim 2 lim 2 lim 2 lim lim 2 lim low low low Low

2 min 1 min 1 min 0-1 min min 0-1 min min min min Strtfrwd 1

cmplx cmplx pres diag mgmt no MDM

Dx Rx # rev rev # ord ord prob proc optns

Circle highest in red Circle highest of 4 in red Circle highest of 3 in red

* Indicates sub-component(s) of MDM that are not documented in the medical record (note - level 1 appropriate only when care provided under physician's supervision without physician present) Interpretation:

1) Level of each MDM component is circled in blue or black ink, whether documented or interpreted by reviewer 2) Highest level in each of the three sections is circled in red ink;

3) An asterisk within the circle of any sub-component indicates that it was not documented in the medical record 4) The calculated level of MDM corresponds to the 2nd lowest of the red circles, which appears in the final column Note: Draw a line through all the levels of care and NPP to indicate the E/M code level submitted

Glossary:

Dx or Rx Options

Dx: number of diagnoses min: minimum Rx: number of treatment options lim: limited mult: multiple ext: extensive Data Reviewed & Ordered

# rev: amount of data reviewed min: minimum cmplx rev: complexity of data reviewed lim: limited # ord: amount of data ordered mod: moderate cmplx ord: complexity of data ordered ext: extensive

Levels of Risk

pres probs: risk of the presenting problem(s) min: minimum diag proc: risk of the diagnostic procedures low: low mgmt optns: risk of the management options mod: moderate

high: high Medical Decision Making

Practical E/M Audit Form: Established Outpatient Visit (p.2)

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Patient: Name: ________________ Chart #: _______ Date of visit: ___/___/____ Code Level Supported by NPP 5 Moderate-High 4 3 2 Minimal 1

* Indicates severity of NPP is not documented in the medical record Interpretation:

1) Circles indicate severity of NPP and level of code warranted by this degree of severity

2) If severity of NPP not documented in medical record, level of severity and corresponding level of warranted care seem appropriate based on remaining documentation; indicated by asterisk (*)

3) If appropriate severity seems to be "moderate to high," choice of code level 4 or 5 based on level of care suggested as appropriate by the examples in CPT's Appendix C and/or highest documented level of risk Note: Draw a line through all the levels of care and NPP to indicate the E/M code level submitted

CPT Descriptors for Severity of NPP: (* intermediate descriptors interpreted by Practical E/M)

Minimal: Problem that may not require the presence of physician, but service is provided under physician's supervision

Minor: Problem runs definite and prescribed course, is tansient in nature, and is not likely to permanently alter health status; OR, has a good prognosis with management and compliance

Low: Problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected

Low - Mod: *Problem where the risk of morbidity without treatment is low to moderate; there is low to moderate risk of mortality without treatment; full recovery without functional impairment is expected

in most cases, with low probability of prolonged functional impairment

Moderate: Problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; prognosis is uncertain, or there is an increased probability of prolonged functional impairment.

Mod - High: *Problem where the risk of morbidity without treatment is moderate to high; there is moderate risk of mortality without treatment; uncertain prognosis or increased probability of

prolonged functional impairment

High: Problem where the risk of morbidity without treatment is high to extreme; there is moderate to high risk of mortality without treatment, or high probability of severe prolonged

functional impairment.

Low-Moderate Low Minor

Practical E/M Audit Form: Established Outpatient Visit (p.3)

Nature of the Presenting Problem

Moderate-High or High

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Patient: Name: ________________ Chart #: ________ Date of visit: ___/___/____

Time for Counseling / Coordination of Care









DOCUMENTATION that > 50% of face-to=face time spent counseling and/or coorinating care









DOCUMENTATION of total amount of FACE-TO-FACE time of visit









DOCUMENTATION of counseling and/or coorination performed

Establ Visit Code Level

Indicated by Time 40 mins 99215 25 mins 99214 15 mins 99213 10 mins 99212 5 mins 99211 Interpretation:

1) Time considered for code selection ONLY if ALL THREE of the above boxes are checked 2) Time value selected must equal or exceed amount in selected box

Note: Draw a line through all the levels of care and NPP to indicate the E/M code level submitted

Practical E/M Audit Form: Established Outpatient Visit (p.4)

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Patient: Name: _______________ Chart #: ________ Date of visit: ___/___/____

Select Correct E/M Code Code Level Code Level Code Level by Key Warranted Indicated Components by NPP by Time

Comprehensive Comprehensive High 99215 99215 99215

Detailed Detailed Mod 99214 99214 99214

Expanded Expanded Low 99213 99213 99213

Prob focused Prob focused Strtfrwd 99212 99212 99212

no M.D. no M.D. no M.D. 99211 99211 99211

no history no exam no MDM









N/A

Level of Level of Level of

History Exam MDM

Interpretation:

1) "Level of history" is value that was determined on page 1

2) "Level of exam" is value that was determined on page 1; selected the higher of 1995 or 1997 Guidelines 3) "Level of MDM" is value that was determined on page 2

4) "Code level by key components" is indicated by the next-to-lowest level circled among the 3 key components 5) "Code level warranted by NPP" is value that was determined on page 3

6) "Code level indicated by Time" is value that was determined on page 4 (if time properly documented) Note: Draw a line through all the levels of care and NPP to indicate the E/M code level submitted

The result of step 4 indicates the level of care performed and documented;

The result of step 5 indicates the level of care that is medically necessary / indicated

The result of step 6 indicates the level of care that is supported by time of counseling and coordination of care Usually, the code level warranted by the NPP establishes the maximum level of care that should be coded If time properly documented, code level determined by time supercedes key components & NPP if it was higher

Conclusion: code submitted:

Code medically indicated based on NPP: Level of care documented:

Code level based on counseling & time:



N/A Select level corresponding to 2nd lowest component

Figure

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References

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