Practical E/M Audit Form: Established Outpatient Visit (p.1)
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1 Patient: Name: Chart #: Date of visit: / / Reviewer: Date of review: / / Medical History Review Select the level corresponding to lowest of the components PFSH ROS HPI Level of History 5 2 elements 0 or more 4-8 elements / Comprehensive Related 4 element 2-9 syst >3 chronic conds Detailed E/M level: 3 0 elements system -3 elements Expanded 2 0 system or no chronology Prob focused Level based on documented "update" of PFSH /ROS no HPI 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 Physical Exam Review (997 Guidelines) Select the level corresponding to guideline description multi-system specialty Ophth & Psych Level of Exam 5 2 in each of 9 all major, ea minor all major, ea minor Comprehensive Related 4 2 elements 2 elements 9 elements Detailed E/M level: 3 6- elements 6- elements 6-8 elements Expanded 2-5 elements -5 elements -5 elements Prob focused Practical E/M Audit Form: Established Outpatient Visit (p.) 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 Physical Exam Review (995 Guidelines) 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 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: level appropriate when care provided under physician's supervision without physician present)
2 Data Gathering Form, History & Exam Section : 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 Ears, nose, & throat Genitourinary Musculoskeletal Psychiatric Endocrine Cardiovascular Integumentary Hematologic/lymphatic Respiratory (skin and/or breast) Allergic/immunologic or UPDATE of ROS from documented previous visit (assess # elements previously) Section 2: Physical Examination 997 Documentation Guidelines: Types of Examinations: Number of organ systems documented General multi-system exam Genitourinary (female) Cardiovascular Ears, nose, & throat Genitourinary (male) Hematologic/lymphatic/immunologic Psychiatric Respiratory Eyes Musculoskeletal Skin Neurological see exam details in "Documentation Guidelines for Evaluation & Management Coding" 995 Documentation Guidelines: Body areas: Head and face Abdomen Back, including spine Neck Genitalia, groin, buttocks Each extremity Chest, incl. breasts & axillae Organ systems: Constitutional Eyes Respiratory Gastroinstestinal Skin 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 EXTENDED examination of (all) affected and symptomatic/related organ systems COMPLETE examination of a single organ system
3 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Established Outpatient Visit (p.2) Medical Decision Making Select the 2nd lowest of the RED circled levels Dx or Rx Options Data reviewed & ordered Levels of Risk Level of MDM 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 min min 0- min min 0- min min min min Strtfrwd 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 appropriate only when care provided under physician's supervision without physician present) ) 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 Glossary: Dx or Rx Options Dx: number of diagnoses Rx: number of treatment options min: minimum 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) diag proc: risk of the diagnostic procedures mgmt optns: risk of the management options min: minimum low: low mod: moderate high: high
4 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Established Outpatient Visit (p.3) Nature of the Presenting Problem Moderate-High or High Code Level Supported by NPP 5 Moderate-High 4 Moderate 3 Low-Moderate Low 2 Minor Minimal * Indicates severity of NPP is not documented in the medical record ) 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 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.
5 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Established Outpatient Visit (p.4) 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 mins mins mins mins 992 ) 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 Crated 2009 by ASA, LLC
6 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Established Outpatient Visit (Summary) Select Correct E/M Code Code Level Code Level Code Level by Key Warranted Indicated Select level corresponding to 2nd lowest component Components by NPP by Time Comprehensive Comprehensive High Detailed Detailed Mod Expanded Expanded Low Prob focused Prob focused Strtfrwd no M.D. no M.D. no M.D no history no exam no MDM N/A Level of Level of Level of History Exam MDM ) "Level of history" is value that was determined on page 2) "Level of exam" is value that was determined on page ; selected the higher of 995 or 997 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) 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
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