E and M Audit Forms M. Cremers

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 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 ___________________ 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 3 Past Family and Social History (PFSH) _____ Past _____ Family _____ Social NOTE: For categories of Subsequent Hospital Care ( ), Subsequent Nursing Facility Care (99307 – 99318), Home Services for Established Patients (99334 – 99337, – 99350) CPT requires only an “interval history.” This means that it is not necessary to record information about the PFSH. History (Parts 1, 2, 3) (read up and down) Type HPI ROS PFSH PF EP Detailed Comp Hx EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2

Eye Examination Components Base Exam Main Exam DF ___VA ___ A/C ___ Retina ___IOP ___ Cornea ___ Macula ___EOM ___ Pupils/Iris ___ C/D Ratio ___VF ___ Sclera ___ Conjunctiva _____Neuro: Orientation x 3 or Mood / Effect 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 1997 Exam Components (Used by Ophthalmologic Practices unless stated otherwise) Type Body Areas / Organ Systems PF 2+ EP 6+ Detailed 9+ Comp Hx 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+ EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2

Medical Decision Making 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 _______________ Medical Decision Making (need 2 of 3 across) TypeDx/MgmtDataRisk SF Low Mod High 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 ______________ Risk of Complications, Morbidity and/or Mortality 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 ____________ EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2