Chart #: _____________ E/M Audit Form

Patient Name: ___________________ Date of service: __ / /__ Provider: _________________ MR #: ______________________

Place of Service: ______________________ Service Type: ___________________ Insurance Carrier: ______________________

Code (s) selected: __________________Code(s) audited: ______________________ Over Under Correct Miscoded

History
History of Present Illness Review of Systems Past, Family & Social History

 Location  Constitutional symptoms PAST MEDICAL

 Quality  Eyes  Current medication
 Severity  Ears, nose, mouth, throat  Prior illnesses and injuries
 Duration  Cardiovascular  Operations and hospitalizations
 Timing  Respiratory  Age-appropriate immunizations
 Context  Gastrointestinal  Allergies  Dietary status
 Modifying factors  Genitourinary
 Associated signs and symptoms  Integumentary FAMILY
 No. of chronic diseases  Musculoskeletal
 Neurological  Health status or cause of death of parents,
 Psychiatric siblings, and children
 Endocrine  Hereditary or high risk diseases
 Hematologic/lymphatic  Diseases related to CC, HPI, ROS
 Allergic/immunologic
SOCIAL
 Living arrangements
PF=Brief HPI  Marital status  Sexual history
EPF=Brief HPI, ROS (Pertinent=1)  Occupational history
Detailed= Extended HPI (4+) + ROS=(2-9) PFSH=1  Use of drugs, alcohol, or tobacco
Comprehensive= Extended HPI + ROS (10 + systems) PFSH=2 Established, 3 New Patient  Extent of education
PFSH Form reviewed, no change PFSH form reviewed, updated PFSH form new  Current employment  Other

**Extended HPI=Status of 3 chronic illnesses with 1997 DG. Some allow for 1995 as well. History ______________

General Multi-System Examination

Constitutional
 3 of 7 (BP, pulse, respir, tmp, hgt, wgt) Gastrointestinal  R.Up Extrem: Motion (+/- pain, crepit)
 General Appearance  Abd (+/- masses or tenderness)  R.Up Extrem: Stability (+/- lux, sublux)
Eyes  Liver, Spleen  R.Up Extrem: Muscle strength & tone
 Hernia (+/-)  L.Up Extrem: Inspect, Palp
 Conjunctivae, Lids
 Anus, Perineum, Rectum  L.Up Extrem: Motion (+/- pain, crepit)
 Eyes: Pupils, Irises
 Stool for occult blood  L.Up Extrem: Stability (+/- lux, sublux)
 Ophthal exam -Optic discs, Pos Seg  L.Up Extrem: Muscle strength & tone
ENT GU/Female
 Female: Genitalia, Vagina  R.Low Extrem: Inspect, Palp
 Ears, Nose
 Female Urethra  R.Low Extrem: Motion (+/-pain, crepit)
 Oto exam -Aud canals,Tymp membr  R.Low Extrem: Stability (+/- lux, laxity)
 Hearing  Bladder
 Cervix  R.Low Extrem: Muscle strength & tone
 Nasal mucosa, Septum, Turbinates
 Uterus  L.Low Extrem: Inspect, Palp
 ENTM: Lips, Teeth, Gums  L.Low Extrem: Motion (+/-pain, crepit)
 Oropharynx -oral mucosa,palates  Adnexa/parametria
GU/Male  L.Low Extrem: Stability (+/- lux, sublux)
Neck  L.Low Extrem: Muscle strength & tone
 Neck  Scrotal Contents
 Penis Skin
 Thyroid  Skin: Inspect Skin & Subcut tissues
Respiratory  Digital rectal of Prostate
Lymphatic  Skin: Palpation Skin & Subcut tissues
 Respiratory effort Neuro
 Percussion of chest  Lymph: Neck
 Lymph: Axillae  Neuro: Cranial nerves (+/- deficits)
 Palpation of chest  Neuro: DTRs (+/- pathological reflexes)
 Auscultation of lungs  Lymph: Groin
 Lymph: Other  Neuro: Sensations
Cardiovascular
 Palpation of heart Musculoskeletal Psychiatry
 Auscultation of heart (& sounds)  Gait (...ability to exercise)  Psych: Judgement, Insight
 Carotid arteries  Palpation Digits, Nails  Psych: Orientation time, place, person
 Abdominal aorta  Head/Neck: Inspect, Palp  Psych: Recent, Remote memory
 Femoral arteries  Head/Neck: Motion (+/-pain,crepit)  Psych: Mood, Affect (depression, anxiety)
 Pedal pulses  Head/Neck: Stability (+/- lux,sublux)
 Head/Neck: Muscle strength & tone
Exam: ______________________
 Extrem for periph edema/varicoscities
Chest  Spine/Rib/Pelv: Inspect, Palp 1995-1=PF, limited 2-7=EPF, extended
 Spine/Rib/Pelv: Motion 2-7=Detailed, 8+ organ systems=Comprehensive
 Inspect Breasts
 Spine/Rib/Pelv: Stability 1997-1-5=PF, 6-11=EPF, 2x6 systems=D
 Palpation of Breasts & Axillae
 Spine/Rib/Pelv: Strength and tone
2 from 9 systems=Comp.
 R.Up Extrem: Inspect, Palp
 Number of Points TABLE OF RISK
Diagnoses/Management Options
Self-limited or minor (Stable, 1 Level of Presenting Problem(s) Diagnostic Procedure(s) Management Options
improved or worsening)  Risk Ordered Selected
Maximum 2 points in this
category. Minimal • One self-limited or minor problem, eg,
cold, insect bite, tinea corporis
• Laboratory tests requiring
venipuncture
•
•
Rest
Gargles
• Chest X-rays • Elastic bandages
Established problem (to 1 • EKG/EEG • Superficial dressings
examining MD); stable or • Urinalysis
• Ultrasound, eg, echocardiography
improved • KOH prep

Established problem (to 2

Low • Two or more self-limited or minor • Physiologic tests not under stress, eg, • Over-the-counter drugs
examining MD); worsening problems pulmonary function tests • Minor surgery with no identified risk
• One stable chronic illness, eg, well • Non-cardiovascular imaging studies factors
New problem (to examining MD); 3 controlled hypertension, non-insulin with contrast, eg, barium enema • Physical therapy
no additional work-up planned  dependent diabetes, cataract, BPH • Superficial needle biopsies • Occupational therapy
• Acute uncomplicated illness or injury, • Clinical laboratory tests requiring • IV fluids without additives
New problem (to examining MD); 4 eg, cystitis, allergic rhinitis, simple
sprain
arterial puncture
• Skin biopsies
additional work-up (e.g.
admit/transfer) Moderate • One or more chronic illnesses with • Physiologic tests under stress, eg, • Minor surgery with identified risk factors
mild exacerbation, progression, or side cardiac stress test, fetal contraction • Elective major surgery (open,
Total effects of treatment stress test percutaneous, or endoscopic) with no
• Two or more stable chronic illnesses • Diagnostic endoscopies with no identified risk factors
• Undiagnosed new problem with identified risk factors • Prescription drug management
uncertain prognosis, eg, lump in breast • Deep needle or incisional biopsy • Therapeutic nuclear medicine
• Acute illness with systemic symptoms, • Cardiovascular imaging studies with • IV fluids with additives
eg, pyelonephritis, pneumonitis, colitis contrast and no identified risk factors, • Closed treatment of fracture or dislocation
Amount and/or Complexity of Data Points • Acute complicated injury, eg, head eg, arteriogram, cardiac without manipulation
injury with brief loss of consciousness catheterization
Reviewed • Obtain fluid from body cavity, eg
lumbar puncture, thoracentesis,
Lab ordered and/or reviewed (regardless of # 1 culdocentesis

ordered)
High • One or more chronic illnesses with • Cardiovascular imaging studies with • Elective major surgery (open,
X-ray ordered and/or reviewed (regardless of # 1 severe exacerbation, progression, or contrast with identified risk factors percutaneous or endoscopic) with
ordered) side effects of treatment • Cardiac electrophysiological tests identified risk factors
• Acute or chronic illnesses or injuries • Diagnostic endoscopies with • Emergency major surgery (open,
Medicine section ordered and/or reviewed 1 that pose a threat to life or bodily
function, eg, multiple trauma, acute
identified risk factors
• Discography
percutaneous or endoscopic)
• Parenteral controlled substances
MI, pulmonary embolus, severe • Drug therapy requiring intensive
Discussion of test results with performing 1 respiratory distress, progressive severe monitoring for toxicity
physician rheumatoid arthritis, psychiatric illness • Decision not to resuscitate or to de-
with potential threat to self or others, escalate care because of poor prognosis
Decision to obtain old record and/or obtain hx 1 peritonitis, acute renal failure
• An abrupt change in neurologic status,
from someone other than patient eg, seizure, TIA, weakness, sensory
loss
Review and summary of old records and/or
obtaining hx from someone other than patient 2
and/or discussion with other health provider
Independent visualization of image, tracing, or 2
specimen (not simply review of report)
Total

Medical Decision Making SF LOW MOD HIGH

Number of Diagnoses or Treatment 1 2 3 4
Options
Amount and/or Complexity of Data to be 1 2 3 4 MDM ______________
Reviewed
Risk of Complications, Morbidity, Minimal Low Moderate High
Mortality
MDM Level=2 out of 3

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