E/M Documentation Based on the Elements: Auditing Tool

E/M <strong>Documentation</strong> Auditor’s InstructionsClient: E/M Code: Time: Date of Service:1. HistoryRefer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, whichbest describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row toidentify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the typeof history.After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.H I S T O R YHPI: Status of chronic conditions:1 condition 2 conditions 3 conditionsORHPI (history of present illness) elements:Location (WHERE) Severity (1-10) Timing WHEN//OFTEN Modifying factors (WHAT WORSENS/LESSENS)Quality (DESCRIBE) Duration (ONSET TO) Context WJATWJEM Associated signs and symptoms (ELSE)ROS (review of systems):Constitutional Ears, nose, GI Integumentary Endo(wt loss, etc) mouth, throat GU (skin, breast) Hem/lymphEyes Card/vasc Musculo Neuro Alrgy/immunoResp Psych All others negativePFSH (past medical, family, social history) areas:Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)Family history (a review of medical events in the patient's family, including diseases which may behereditary or place the patient at risk)Social history (an age appropriate review of past and current activities)NoneStatus of1-2 chronicconditionsBrief(1-3)Pertinent toproblem(1 system)NoneExtended(2-9 systems)Pertinent1 history area)Status of 3chronicconditions*CompleteExtended(4 or more)**Complete***Complete(2 or 3historyareas)*Complete HxAllow if unable to obtain & describe condition preventing.PROBLEMFOCUSED EXP.PROB.FOCUSED DETAILEDCOMPRE-HENSIVE**Complete ROS 10 or more, or some systems with statement "all others neg.“***Complete PFSH 2 history areas: a) Established patients - office (outpatient) care; b) Emergency department.2. Examination3 history areas: a) New patients - office (outpatient) care, domiciliary care, home care; b) Consultations; c) Initialhospital care; d) Hospital observation; e) Initial Nursing Facility Care.NOTE: Subsequent Hospital & Subsequent Nursing Facility Care E/M services require only an intervalhistory, it is not necessary to record information about the PFSH. Refer to procedure code descriptions.Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.Circle the type of examination within the appropriate grid in Section 5.EXAMSYSTEM/BODY AREA 3/7 vital signs: sitting or standing BP, supine BP, pulse rate and regularity, respiration, temperature,height, weightConstitutional General appearance Muscle strength and tone Gait and Station Musculoskeletal Speech Thought process Associations Abnormal/psychotic thoughts Judgment and insight Orientation Recent and remote memory Attention and concentration Language Fund of knowledge Mood and affect1 – 5 bulletsAt least 6 bulletsAt least 9 bulletsAll bullets in Constitutional and Psychiatric boxes and 1 bullet in Musculoskeletal box.PsychiatricPROBLEM FOCUSED EXAMEXPAND PROB FOCS’D EXAMDETAILED EXAMCOMPREHENSIVE EXAM

3. Medical Decision MakingNumber of Diagnoses or Treatment OptionsIdentify each problem or treatment option mentioned in the record.Enter the number in each of the categories in Column B in the tablebelow. (There are maximum number in two categories.) Do notcategorize the problem(s) if the encounter is dominated bycounseling/coordinating of care, and duration of time is not specified.In that case, enter 3 in the total box.M E D I C A L D E C I S I O N M A K INumber of Diagnoses or Treatment OptionsA B X C = DProblem(s) StatusNumber Points ResultSelf-limited or minor(stable, improved or worsening)Max = 2 1Est. problem (to examiner); stable, improved 1Est. problem (to examiner); worsening 2New problem (to examiner); no additional3workup plannedMax = 1New prob. (to examiner); add. workup planned 4TOTALMultiply the number in columns B & C and put the product in column D.Enter a total for column D.Bring total to line A in Final Result for Complexity (table below)Amount and/or Complexity of Data ReviewedFor each category of reviewed data identified, circle the number inthe points column. Total the points.Amount and/or Complexity of Data ReviewedReviewed DataPointsReview and/or order of clinical lab tests 1Review and/or order of tests in the radiology section of CPT 1Review and/or order of tests in the medicine section of CPT 1Discussion of test results with performing physician 1Decision to obtain old records and/or obtain history fromsomeone other than patientReview and summarization of old records and/or obtaininghistory from someone other than patient and/or discussion ofcase with another health care providerIndependent visualization of image, tracing or specimen itself(not simply review of report) 2TOTALBring total to line C in Final Result for Complexity (table below)Risk of Complications and/or Morbidity or Mortality Use the risk table below as a guide to assign risk factors. It is understood that the table below does notcontain all specific instances of medical care; the table is intended to be used as a guide. Circle the mostappropriate factor(s) in each category. The overall measure of risk is the highest level circled.Enter the level of risk identified in Final Result for Complexity (table below).Level ofRiskMinimalLowPresenting Problem(s)• One self-limited or minor problem• Two or more self-limited or minor problems• One stable chronic illness• Acute uncomplicated illnessDiagnostic Procedure(s)Ordered• Laboratory tests requiring venipuncture• EKG/EEG• Urinalysis• RestManagement OptionsSelected• Over-the-counter drugs12ModerateHigh• One or more chronic illnesses with mildexacerbation, progression, or side effects of treatment• Two or more stable chronic illnesses• Undiagnosed new problem with uncertain prognosis,• Acute illness with systemic symptoms• One or more chronic illnesses with severeexacerbation, progression, or side effects of treatment• Acute or chronic illnesses or injuries that may pose a threat tolife or bodily function (self//other)• Prescription drug management• Drug therapy requiring intensive monitoring for toxicityFinal Result for ComplexityDraw a line down any column with 2 or 3 circles to identify the type of decision makingin that column. Otherwise, draw a line down the column with the 2nd circle from the left.After completing this table, which classifies complexity, circle the type of decisionmaking within the appropriate grid in Section 5.Final Result for Complexity≤ 1 2 3 ≥ 4A Number diagnoses orMinimal Limited Multiple Extensivetreatment options4. TimeIf the physician documents total time and suggests that counseling or coordinating care dominates(more than 50%) the encounter, time may determine level of service. <strong>Documentation</strong> may refer to:prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, riskreduction or discussion with another health care provider.B Highest Risk Minimal Low Moderate HighCAmount and complexityof data≤ 1Minimalor lowType of decision makingSTRAIGHT-FORWARD2Limited3Multiple≥ 4ExtensiveLOW MODERATE HIGHCOMPLEX. COMPLEX. COMPLEX.Face-to-face in outpatient settingDoes documentation reveal total time? Time: Unit/floor in inpatient setting Yes NoDoes documentation describe the content of counseling or coordinating care?Does documentation reveal that more than half of the time was counselingor coordinating care?Yes NoIf all answers are "yes", select level based on time.5. L E V E L O F S E R V I C E5. New Office Established OfficeRequires 3 components within shaded areaRequires 2 components within shaded areaMinimalHistory P EPF D C CproblemPF EPF D Cthat mayExamination P EPF D C Cnot requirePF EPF D CfComplexity S SF L M H physicianSF L M HTimeCode10”9920120”9920230”9920345”9920460”992055”9921110”9921215”9921325”99214Yes40”99215No