E and M Audit Forms

1. E and M Audit Forms M. Cremers - 2010

2. EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2 HISTORY – Part 2 Patient response to questions asked by nurse, technician, or doctor Review of Systems (ROS) _____ Constitutional _____ MS _____ Eyes _____ Integumentary _____ ENT _____ Neuro _____CV _____ Psych _____ Respiratory _____ Endocrine _____ GI _____ Heme/Lymp _____GU _____ Allergic/Immun HISTORY – Part 1 Chief Complaint (CC) The Chief Complaint (CC) or reason for the visit must be documented for all patient encounters CC: __________________________________ ______ Location _____________________ ______ Quality ______________________ ______ Severity _____________________ ______ Duration _____________________ ______Timing _______________________ ______ Context ______________________ ______ Mod Factors __________________ ______ Signs/ Sxs ___________________ NOTE: Doctor must have asked / noted at least one of the above listed 10 components in the patient’s chart note in order to utilize the following statement:: “All remaining systems are negative”. This then will count towards a comprehensive ROS. History - Part 3 Past Family and Social History (PFSH) _____ Past _____ Family _____ Social History (Parts 1, 2, 3) (read up and down) Type HPI ROS PFSH PF 1-3 --- --- EP 1-3 1 --- Detailed 4+ 2-9 1 Comp Hx 4+ 10+ 2-3 NOTE: For categories of Subsequent Hospital Care (99231-99233), Subsequent Nursing Facility Care (99307 – 99318) , Home Services for Established Patients (99334 – 99337, 99347 – 99350) CPT requires only an “interval history.” This means that it is not necessary to record information about the PFSH.

3. EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2 Exam (Doctor physically examines the patient) Body AreasOrgan Systems _____ Head ____ Constitutional ____ M/S _____ Neck ____ Eyes ____ Integum. _____Chest ____ ENT ____ Neuro _____Abdomen ____ CV ____ Psych _____Genitalia ____ Respiratory ____ Heme/ Lymph / Immun _____Back ____ GI ____ GU Each Extremity ___Left Arm ___ Left Leg ___ Right Arm ___ Right Leg Eye Examination Components Base Exam Main ExamDF ___VA ___ A/C ___ Retina ___IOP ___ Cornea ___ Macula ___EOM ___ Pupils/Iris ___ C/D Ratio ___VF ___ Sclera ___ Conjunctiva _____Neuro: Orientation x 3 or Mood / Effect 1995 Exam Components (Used by most specialties unless Company Guidelines state otherwise) Type Body Areas / Organ Systems PF 1 EP 2-4 Detailed 5-7 Comp Hx 8+ 1997 Exam Components (Used by Ophthalmologic Practices unless stated otherwise) Type Body Areas / Organ Systems PF 2+ EP 6+ Detailed 9+ Comp Hx 13+

4. EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2 Medical Decision Making (need 2 of 3 across) Type Dx/Mgmt Data Risk SF 1 1 1 Low 2 2 2 Mod 3 3 3 High 4+ 4+ 4+ Risk of Complications, Morbidity and/or Mortality 1 - 1 Minor problem or 1 self limited problem, basic lab and/or x-ray, no meds, rest, elastic bandages, superficial dressings. 2 – 2 Minor problems, 1 chronic, 1 acute, Ptts, BE, superficial needle, Bx, clinical lab test requiring arterial puncture, skin Bx, OTC drugs, minor surgery w/ no risk factors, physical therapy, occupational therapy, IV fluids w/out additives. 3 – 1 or more chronic worsening, 2 chronic stable, 1 potential serious, undiagnosed new prob., acute illness with systemic symptoms, acute, complicated injury, deep needle or incisional Bx, obtain body fluid from body cavity, minor surgery w/ no identified risk factors, prescription drug mgmt, IV fluids w/ additives, Stress TMT/MRI, Chemotherapy drugs 4 – 1 or more chronic illness w/ severe exacerbation or progression or side effects, acute or chronic illness or injury that may pose a threat to life or bodily function, an abrupt change in neurological status, elective major surgery w/ identified risk factors, emergency surgery or referral, potential controlled substances, drug therapy requiring intensive monitoring for toxicity, decision not to resuscitate or de-escalate care because of poor progress. TOTAL Points ____________ Medical Decision Making Amount/Complexity of Data 1 Pt – Order &/or review clinical lab's) (80,000 section in CPT Book) 1 Pt – Order &/or review radiological test (70,000 section in CPT Book) 1 Pt – Order &/or review tests in Medicine section (90,000 section in CPT Book) 1 Pt – Discussion of test results w/ performing provider. This is when the provider calls up to discuss the test results w/ the physician who performed the test. 2 Pt – Independent/direct review of image, tracing or specimen. When the provider personally reviews & interprets a test, x-ray, etc. in the documentation, use phrases as “my independent review of the x-ray shows…” 1 Pt – Decision to obtain old records or history from someone other than the patient. In the documentation, the provider should indicate that old records were ordered from the hospital/other clinic, or that the provider is going to obtain the Hx of the patient from another person. 2 Pt – Review and summarize old records and/or obtain history from someone other than the patient. TOTAL Points ______________ Diagnostic / Treatment Options 1 Pt – Minor Problem (max of 2 pts) 2 Pt – Established Stable 2 Pt – Established Worsening 3 Pt – New w/out Additional Work Up (Max 1 pt) 4 Pt – New w/ Additional Work Up TOTAL Points _______________