E/M Audit Form

Chart #: ________________

Patient Name: ___________________________ D.O.S.: ___/___/_____ Provider: ____________ MR#:______________

Place of Service: _____________________ Service Type: _______________________ Ins. Carrier: _________________

Code(s) Selected: __________________ Code(s) Audited: ___________________ Over Under Correct Miscoded

History of Present Illness Review of Systems History Past, Family, & Social
Location Constitutional Symptoms PAST MEDICAL
Quality Eyes Current Medication
Duration Ears, Nose, Mouth, Throat Prior Illnesses and Injuries
Timing Cardiovascular Operations and Hospitalizations
Content Respiratory Age Appropriate Immunizations
Modifying Factors Gastrointestinal Allergies
Associated Signs and Genitourinary Dietary Status
Symptoms Integumentary
No. of Chronic Diseases Musculoskeletal FAMILY
Health status or cause of death of parents, sibling, and children
Neurological
Hereditary or high risk diseases
Psychiatric
Diseases related to CC, HPI< ROS
Endocrine
Hematologic / Lymphatic
SOCIAL
Allergic / Immunologic
Living Arrangements
Marital Status Sexual History
Occupational history
Use of drugs, alcohol, or tobacco
Extent of Education
Current employer Other

Hx:________________________________________

PF = Brief HPI
EPF= Brief HPI, ROS (Pertinent=1)
Detailed= Extended HPI (4+) + ROS = (2-9) PFSH = 1
Comprehensive = Extended HPI + ROS (10 + systems) PFSH = 2 Established, 3 New Patient
PFSH Form Reviewed, No Change PFSH form reviewed, Updated PFSH form New
Constitutional Cardiovascular
*** Extended HPI = Status of 3 chronic GU/Male
illnesses with 1997 DG. Some allow for 1995 as well. R. Low Extrem: Inspect, Palp
3 of 7 (BP, pulse, respire, tmp, hgt, wgt) Palpation of heart Scrotal Contents R. Low Extrem: Motion (+/- Pain, Crepit)
General Appearance Auscultation General
of heart (&Multi-
sounds) System Examination
Penis R. Low Extreme: Stability (+/- Lux,
Eyes Carotid arteries Digital rectal of Prostate Sublux)
Conjunctivae, Lids Abdominal aorta Lymphatic R. Low Extreme: Muscle Strength &
Eyes; Pupils, Irises Femoral arteries Lymph: Neck tone
Ophthal Exam Optic Discs, Pos Seg Pedal pulses Lymph: Axillae L. Low Extrem: Inspect, Palp
ENT Extreme for periph Lymph: Groin L. Low Extrem: Motion (+/- Pain, Crepit)
Ears, Nose edema/varicosities Lymph: Other L. Low Extreme: Stability (+/- Lux,
Oto exam Aud canals, Tymp membr Chest Musculoskeletal Sublux)
Hearing Inspect Breasts Gait (ability to exercise) L. Low Extreme: Muscle Strength &
Nasal mucosa, Septum, Turbinates Palpation of Breasts & Axillae Palpation Digits, Nails tone
ENTM: Lips, Teeth, Gums Gastrointestinal Head/Neck: Inspect, Palp Skin
Oropharynx oral mucosa, palates Abd (+/- masses or tenderness) Head/Neck: Motion (+/- Pain Crepit) Skin: Inspect Skin & Subcut tissues
Neck Liver, Spleen Head/Neck: Stability (+/- Lux., Sublux) Skin: PalpationSkin & Subcut tissues
Neck Hernia (+/-) Head/ Neck: Muscle Strength &Tone Neuro
Thyroid Anus, Perineum, Rectum Spine/Rib/ Pelv: Motion Neuro: Cranial Nerves (+/- Deficits)
Respiratory Stool for occult blood Spine/Rib/Pelv: Stability Neuro: DTRs (+/- pathological reflexes)
Respiratory Effort GU/ Female Spine/Rib/Pelv: Strength and Tone Neuro: Sensations
Percussion of chest Female: Genitalia, Vagina Psychiatry
R. Up Extrem: Inspect, Palp
Palpation of chest Female Urethra Psych: Judgment, Insight
R. Up Extrem: Motion (+/- Pain, Crepit)
Auscultation of chest Bladder Psych: Orientation (time, place, person)
R. Up Extrem: Stability (+/- Lux, Sublux)
Cervix Psych: Recent (Remote memory)
R. Up Extrem: Muscle Strength & tone
1995-1=PF, Limited 2-7=EPF, extended Uterus Psych: Mood, Affect (anxiety, depression)
L. Up Extrem: Inspect, Palp
2-7=Detailed, 8+ organ systems=Comprehensive Adenexa/parametria Exam: ___________________________
1997-1-5=PF, 6-11=EPF, 26 systems=D
L. Up Extrem: Motion (+/- Pain, Crepit)
L. Up Extrem: Muscle Strength & tone
5. Level of Service

Outpatient and New Office/ER Established Office

ER
Requires 3 Components within shaded area Requires 2 Components within shaded area
History PF EPF D C C Minimal PF EPF D C
ER:PF ER:EPF ER:EPF ER:D ER:C problem that
Examination PF EPF D C C may not PF EPF D C
ER:PF ER:EPF ER:EPF ER:D ER:C require
Complexity of SF SF L M H presence of SF L M H
Medical Decision ER:SF ER:L ER:M ER:M ER:H physician
Average time 10New 20 New 30 New 45 New 60 New 5 10 15 25 40
(minutes) (ER (99201) (99202) (99203) (99204) (99205) (99211) (99212) (99213) (99214) (99215)
has no average ER ER ER ER ER
time) (99281) (99282) (99282) (99284) (99285)
Level I II III IV V I II III IV V

Initial Hospital/Observation Subsequent Hospital

Inpatient
Requires 3 Components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of SF/L M H SF/L M H
Medical Decision
Average time 30 initial hosp 50 initial hosp 70 initial hosp 15 Subsequent 25 Subsequent 35 Subsequent
(minutes) (ER has (99221) (99222) (99223) (99231) (99232) (99233)
no average time) Observ. Care Observ. Care Observ. Care
(99218) (99219) (99220)
Level I II III I II III

Other Nursing
Initial Nursing Facility Subsequent Nursing Facility Facility (Annual
Assessment)
Nursing Facility Care Requires 3
Requires 3 components within components
Requires 2 components within shaded area
shaded areas within shaded
area
History D/C C C PF interval EFP interval D C D interval
interval interval
Examination D/C/ C C PF EFP D C C
Complexity of Medical Decision SF/L M H SF L M H L/M
Average Time (minutes) 25 35 45 10 15 25 35 30
(99304) (99305) (99306) (99307) (99308) (99309 (99310) (99318)
Level I II III I II III IV

Domiciliary, Rest
New Established
Home (eg, Boarding
Home), or Custodial
Requires 3 components within shaded area Requires 2 components within shaded area
Care and Home Care
History PF EPF
PF EPF D C C D interval C interval
interval interval
Examination PF EPF D C C PF EPF D C
Complexity of Medical
SF L M M H SF L M M/H
Decision
Average Time (minutes) 20 30 45 60 75 15 25 40 60
Domiciliar Domiciliar Domiciliar Domiciliar Domiciliary Domiciliar Domiciliar Domiciliar Domiciliary
y y y y (99328) y y y (99337)
(99324) (99325) (99326) (99327) Home Care (99334) (99335) (99336) Home Care
 Home Care Home Care Home Care Home Care Home Care Home Care Home Care
(99345) (99350)
(99341) (99342) (99343) (99344) (99347) (99348) (99349)
Level I II III IV V I II III IV
PF= Problem Focused EPF= Expanded Problem D= Detailed C= Comprehensive SF= Straightforward

L=Low M=Moderate H= High

Number of
Diagnose/
Points
Management
Options
Self-Limited or
minor (Stable,
improved, or
worsening) 1
Maximum 2
points in this
category Table of Risk
Established
Level of
problem (to Presenting Problems Diagnostic Procedure(s) Management Options Selected
Risk
examining MD); 1
-Laboratory tests requiring venipuncture
stable or -Chest X-rays
- Rest
improved -One self-limited or minor problem
-EKG/EEG
-Gargles
New problem (to Minimal -Urinalysis
(cold, insect bite, tinea corporis) -Elastic bandages
-Ultrasound (e.g. echocardiogram)
examining MD); -KOH prep
-Superficial Dressing
3
no additional
work-up planned -Two or more self-limited or minor - Physiologic test not under stress (e.g.
4 problems pulmonary function test) -Over-the-counter drugs
New problem (to
-One stable chronic illness (e.g. well -Non-cardiovascular imaging studies with -minor surgery with no
examining MD); controlled hypertension, non-insulin contrast (e.g. barium edema) identified risk factors
Low
additional work- dependent diabetes, cataract, BPH) -Superficial needle biopsy -Physical therapy
up (e.g. -Acute uncomplicated illness or injury -Clinical laboratory test requiring arterial -Occupational therapy
Amount Points
(e.g. cystitis, allergy rhinitis, simple puncture -IV fluids without additives
admit/transfer)
and/or sprain) -Skin biopsies
Total -One or more chronic illnesses with
Complexity of
mild exacerbation, progression, or
Data Reviewed side effects
-Physiological tests done under stress (e.g.
-Minor surgery with identified
Lab ordered and/or 1 cardiac stress test, fetal contraction stress test)
-Two or more stable chronic illnesses risk factors
- Diagnostic
SF endoscopiesLow with no identified Mod High
reviewed (regardless of # Medical Decision Making
-Undiagnosed new problem with -Elective major surgery (open,
risk factors
1 2 3 percutaneous, endoscopic)
4 with
ordered) Number of Diagnosis or Treatment
uncertain prognosis (e.g. lump in
- Deep needle incisional biopsy
Moderate
Options breast) no identified risk factors
X-ray ordered and/or 1 -Cardiovascular imaging studies with contrast
-Acute illness with systemic 3 - Therapeutic nuclear medicine
Amount and/or Complexity of Data to and no1identified risk factors2 (e.g. 4
reviewed (regardless of # symptoms (e.g. pyelonephritis, -IV fluids with additives
be Reviewed arteriogram, cardiac catheterization)
ordered) pneumonitis, colitis, -Closed treatment of fracture or
-Obtain fluid from body cavity
Minimal Low (e.g. lumbar Moderate High
Medicine section (90701- 1 Risk of Complications,
-Acute complicated Morbidity,
injury (e.g. head dislocation without manipulation
puncture, thoracicentesis, culdocentesis
99199) ordered and/or Mortality injury with brief loss of
consciousness)
MDM Level=2 out of 3
reviewed -Elective major surgery (open
1 MDM percutaneous or endoscopic)
Discussion of test results -One or more chronic illnesses with
with identified risk factors
with performing sever exasperation, progression, or -Cardiovascular imaging studies w/contrast
-Emergency major surgery (open
side effects of treatment with identified risk factors
Physician percutaneous or endoscopic)
1 -Acute or chronic illnesses/injury that -Cardiac electrophysiological tests
Comments: ____________________________________________________________________________
Decision to obtain old High
pose a threat to life or bodily function -Diagnostic Endoscopes with identified risk
-Parenteral controlled substances
record and/or obtain Hx -Drug therapy requiring
(e.g. multiple trauma, acute MI, factors
______________________________________________________________________________________ intensive monitoring for toxicity
from someone other than pulmonary embolus, severe -Discography
-Decision not to resuscitate or to
respiratory distress,
patient deescalate care because of poor
2
______________________________________________________________________________________
Review and summary of prognosis
old records and/or ______________________________________________________________________________________
obtaining Hx from
someone other than ______________________________________________________________________________________
patient and/or decision
with other health
Chart Note ______________________________________________________________________________________
provider
Dictated visualization
Independent Handwritten Other Services or Modalities: ____________________________________________________________
of image, tracing, or
2
specimen (not simply Auditors Signature: ____________________________________________________________________
review of report)
Total
 Form Illegible
Signature
Note Signed
Missing