E & M CPT Coding Review and Audit Tool by MDTools

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E & M CPT® CODING REVIEW AND AUDIT TOOL
Medicare E&M Coding Audit Tool

Medicare E&M Coding Audit Tool

This E & M CPT® Coding Review and Audit Tool is intended for use by medical professionals and coding experts to review the accuracy of coding and/or the adequacy of medical record documentation of Evaluation and Management services. The tool can be used to investigate specific encounters or to profile the coding and documentation patterns of individual physicians. If used for physician profiling, a random sample of encounters should be reviewed. We recommend a sample size of at least 10 encounters.

The E & M CPT Coding Review and Audit Tool calls for information as documented in the medical record for the encounter and assigns a CPT code based on this information. If this code differs from the code that was billed for the encounter, a coding and/or documentation problem (or a problem pattern) has been revealed. Further investigation and corrective action can then be undertaken as part of the practice's compliance program.

MDTools has tested and used this E & M CPT Coding Review and Audit Tool extensively, and we believe that will provide reliable and accurate results.

CPT Coding Review Audit Tool

Date of Visit
Initial Client E&M Code
Chart ID
ICD10 Reference
Select one of the following:
Is Chief Complaint documented?

1.	HISTORY
	( Check ALL elements documented for parts A, B, and C.)

A.

History of Present Illness(HPI)

( Describes the development of patient's illness.)

Location		Quality*		Severity		Duration
	*Quality=the special attribute which makes it unlike anything else
Timing		Context*		Mod Factors		Signs & Symptoms
	*Context=interrelated conditions in which exists or occurs.

Please list any chronic or inactive conditions that were addressed during this visit:

B.

Review of Systems(ROS)

(Inventory of body systems/areas, may be completed by patient)

		Constitutional		Eyes		E,N,M,T
Cardio.		Respir.		Gastro.		Genitour
Musculo.		Integu.		Neuro.		Psych.
Endo.				Hemo./Lymph.		All./Immune
		All others negative

None (no systems addressed)
Problem Pertinent (system directly related to illness)
Extended (2 - 9 systems)
Complete (10 or more systems)

C.

Past, Family, Social History (PFSH)

(Review patient's history - new patients require all 3, established patients require 2)

Past History
Family History
Social History

None (No PFSH addressed)
Pertinent (specific info. from 1 area)
Complete (specific info. from 2 for established, 3 for new)

Notes on History

2.	EXAM
	You should use both the 1995 and the 1997*** Guidelines.

Areas:
		Head		Abdomen		Genitalia
Extremities		Back		Neck		Chest

Systems:

		Const.		E,N,M,T		Respir.
Cardio		Gastro.		Genito.		Hem/Lymph/Imm
Musculo.		Skin.		Neuro.		Psych.
Eyes		Endo.

Was a complete exam of one system documented?

Focused ('95 = 1 area or system) ('97 = 1 - 5 elements)
Expanded ('95 = Limited exam of 2 -7 areas or systems) ('97 = 6 elements)
Detailed ('95 = "Extended" exam of 2 - 7 areas or systems) ('97 = 12 elemets)
Comprehensive ('95 = Complete exam of 1 sys. for specialists or 8 or more systems)
('97 = multisystem - 2 elements in each of 9 systems)

Was this an Expanded or Detailed exam?
Note:

Detailed exam is defined as an "Extended" examination. Verify with your medicare carrier its definition of "Expanded" versus "Detailed." If carrier specifies "Detailed" is 5-7 areas or systems, choose the "Detailed" option in the dropdown box.

Select your exam form:

Notes on Exam

3.	MEDICAL DECISION MAKING

A.	PRESENTING PROBLEMS
	Identify the problems mentioned in record. Enter the # of problems in each category in column 2 ( note the maximum number of problems recognized in "self-limiting" and "New problem" categories). Do NOT categorize the problems if the encounter is dominated by counseling or coordination of care and the duration of time is not specified (if this is the case, enter 3 for the Total).

PROBLEM CATEGORIES	NUMBER	POINTS	SCORE
Self-Limiting or minor; stable/improving (Max 2)		1
Established problem; stable/improved		1
Established problem; worsening		2
New problem; no additional work up planned (Max 1)		3
New problem; additional work up planned		4

B.	TYPE OF DATA
	Review each category of data below and circle the number in the points column if applicable. Enter the Total Number of Circled points.

	TYPE OF DATA (AMOUNT AND COMPLEXITY)
	Review and/or order clinical lab tests (CPT section 80047 - 89398)
	Review and/or order tests from radiology section of CPT (70000 - 79999 - including nuclear medicine & all imaging, but excluding echocardiography & cardiac caths)
	Review and/or order tests in the medicine section of CPT (9000 - 99000 - EEG, EKG, Echocardiography, cardiac cath, non-invasive vascular studies pulmonary function studies)
	Discussion of test results with performing physician
	Independent review of image, tracing or specimen
	Decision to obtain old records and/or obtain history from someone other than patient
	Review and summarization of old records and/or obtaining history from someone other than patient or discussion of case with another health care provider

C.	LEVEL OF RISK

NOTE: THE HIGHEST RISK IN ANY CATEGORY DETERMINES THE OVERALL LEVEL OF RISK

Level of Risk	Presenting Problem(s) Risk is based on the risk anticipated between current & next encounter	Diagnostic Procedure(s) Ordered Risk is based on the risk during & immediately after procedure or treatment	Management Options Selected Risk is based on the risk during & immediately after procedure or treatment

MINIMAL	One self-limited or minor problem, e.g. cold, insect bite, tinea corporis	Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, e.g. echocardiography KOH prep	Rest Gargles Elastic bandages Superficial dressings Drug maintenance (refill meds)
LOW	Two or more self-limited or minor problems One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain	Physiologic tests not under stress, e.g. pulmonary function tests Non-cardiovascular imaging studies with contrast, e.g. barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies	Over the counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
MODERATE	One or more chronic illnesses with mild exacerbation, progression or side effects of treatment. Two or more stable chronic illnesses. Undiagnosed new problem with uncertain prognosis, e.g. lump in breast, rectal bleeding Acute illness with systematic symptoms, e.g. pyelonephritis, pneumonitis, colitis Acute complicated injury, e.g. head injury with brief loss of consciousness	Physiologic tests under stress, e.g. cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors, e.g. arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis	Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management or Prescribing new drug (add/change/delete meds) Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation
HIGH	One or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status, e.g. seizure, TIA, weakness or sensory loss	Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography	Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Notes on Medical Decisionmaking

4.	Visit/Consultation/Examination Time

What was the total time of the examination/visit? (minutes)

Was documentation available indicating that over 50% of the visit was spent in counseling & coordination of care?

Auditor's Notes Section

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