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Last Modified: 7/31/2014
OFFICE VISITS & CONSULTS - Audit Tool
Patient Name
MRN
New Patient Office Visit = 9920x
Billed
Audited
Established Patient Office Visit = 9921x
Auditor
Office Consult = 9924x
HISTORY
HPI
ROS
☐ ☐ Location (site on body)
☐Quality (characteristic: throbbing, sharp; how
the problem feels, looks, behaves: acute,
chronic, stable, worsening, waxing/waning)
☐Severity (1/10, intensity)
☐Duration (how long for problem/episode)
☐Timing (when it occurs: throughout the day,
morning, at night continuously, etc)
☐Context (under what circumstances does the
patient experience the symptom/problem)
☐Modifying Factors (what makes it better or
worse)
☐Assoc. Signs/Symptoms (what else is
happening when it occurs)
Status of Chronic Conditions ☐ 1-2 ☐3
☐Constitutional (Fevers, chills, weight change, fatigue, general health-feeling
okay, sweating, appetite)
☐Eyes (Wears glasses, blurry vision, eye problems)
☐Ear, Nose, Mouth, Throat (Hearing loss, ringing in ears, earaches, drainage,
sinus problems, nose bleeds, bad breath, sores or bleeding in mouth, voice
change, snoring)
☐Cardiovascular (Chest pain, chest tightness, swelling of feet or hands,
palpitations, no edema)
☐Respiratory (Cough, SOB, wheezing, sputum, coughing up blood)
☐GI (Change in bowel habits, nausea, vomiting, diarrhea, constipation, belly pain,
rectal bleeding)
☐GU (Frequency, pain or burning on urination, change in force when urinating,
blood in urine, incontinence, pain with menstruation, change in menstrual habits,
testicle pain)
☐Musculo (Joint pain or stiffness, swelling, muscle pain, back pain, difficulty
walking, gait)
☐Integumentary - Skin/Breast (Rash, itching, change in skin color, varicose veins,
breast pain, lump)
☐Neuro (Headaches, lightheadedness, dizziness, tremors, numbness or tingling,
weakness, paralysis)
☐Psych (Memory loss, confusion, suicidal ideation, depression, anxiety,
hallucinations, behavior problems)
☐Endocrine (Excessive thirst or urination, heat or cold intolerance, dry skin, night
sweats)
☐Hem/lymph (Bleeding or easy bruising, anemia, phlebitis, enlarged glands)
☐Allergic/Imm (Sneezing, itching eyes, rhinorrhea, nasal obstruction, or recurrent
infections)
☐“All others negative”
PFSH
☐Past Medical (experiences with illnesses,
operations, injuries and treatments, updated
medication list and allergies)
☐Family (a review of pertinent family medical
events, diseases, and hereditary conditions that
may place patient at risk)
☐Social (age appropriate review of past and
current activities – employment, use of
drugs/alcohol/tobacco, marital status, level of
education, sexual history)
☐ History was unobtainable due to ______.
HPI
☐ 1-3
ROS
☐ None
☐ 1-3
Or status of 1-2
chronic conditions ☐
☐1
PFSH
☐ None
☐ None
HISTORY
LEVEL
(choose lowest)
Problem
Focused
☐
Expanded Problem
Focused
☐
☐ 2-9
☐ 1-2 (new pt/consult)
☐ (1 if Est pt)
☐ 4+
Or status of 3 chronic
conditions ☐
☐ 10+
☐ 3 (new pt/consult)
☐ (2-3 if Est pt)
Detailed
☐
Comprehensive
☐
☐ 4+
1995 EXAM
☐Constitutional (vital signs, general appearance, no acute distress) ☐Hem/lymph/Imm (no lymph nodes palpable)
☐Eyes
☐Ear, Nose, Mouth, Throat (teeth)
☐Cardiovascular (carotids, edema, pedal pulses, capillary refill)
☐Respiratory (percussion/auscultation)
☐GI (GI: no tenderness, HSM, normal bowel sounds )
☐GU
☐Musculo (clubbing, cyanosis, CVA tenderness)
☐Integumentary - Skin/Breast (rashes, tattoos, piercings)
☐Neuro
☐Psych (affect – alert & oriented)
OK to use “negative” or “normal” alone but if “abnormal” details must be added.
☐ Head (Including face) ☐ Chest (including breast/axillae)
☐ Neck
☐ Back
# of organ
systems/body areas
EXAM LEVEL
Limited to affected organ
system/body area
Problem Focused ☐
☐ Abdomen
☐ Left Arm
☐ Genitalia/groin/buttocks ☐ Left Leg
2-4
Expanded Problem Focused ☐
5-7
Detailed ☐
☐ Right Arm
☐ Right Leg
8+
Organ Systems
Comprehensive☐
Medical Decision Making Elements
A) # OF DIAGNOSIS/MANAGEMENT
OPTIONS (Problems to Examining Provider)
Self-limited or minor (stable, improved,
worsening) = 1 pt each, Max = 2
Est. problem (to examiner) stable, improved
= 1 pt each
Est. problem (to examiner) worsening = 2 pt ea
New problem (to examiner) no additional
workup = 3 pt each
New problem (to examiner) additional workup
= 4 pt each
B) AMOUNT AND/OR COMPLEXITY OF DATA TO REVIEW
(Data Reviewed by Examining Provider)
Points
A) Total
Points
Review and/or order LAB tests
1
Review and/or order RADIOLOGY tests
Review and/or order MEDICINE tests
1
1
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review & summarization of old records and/or obtaining history
from someone other than the patient and/or discussion of case
with another health care provider
Independent visualization of image, specimen or tracing (NOT
simply review of report)
1
1
2
2
B) Total
C) RISK OF COMPLICATIONS, MORBIDITY and/or MORTALITY
RISK
Presenting problems
Dx procedures ordered
☐ 1 minor or self-limited (cold, insect
☐ Venipuncture, CXR, EKG, EEG,
Min
bite, tinea corporis)
UA, ultrasound/echo, KOH prep
☐ 2 or more minor;
☐ Physiologic tests NOT under
1
stable
chronic
problem;
Acute
stress; Non CV imaging w/ contrast
Low
uncomp illness/injury (cystitis, sprain,
(barium enema); Superficial needle
allergic rhinitis)
biopsy; skin biopsies
☐ Mild exac of chronic prob; 2 stable
☐ Physiologic tests under stress;
chronic prob; Acute illness + system Sx
Dx endoscopies NO risk factors;
(pyelonephritis,
colitis);
Acute
Deep needle or incisional bx; CV
Mod
complicated injury (head injury brief loss imaging + contrast; Obtain fluid
of consciousness); Undiagnosed new
from body cavity
problem w/ uncertain prognosis
☐ Severe exac of chronic prob or side
☐ CV imaging + contrast, risk
effect of tx; Acute or chronic illness
factors; Card electrophysiological
High
posing threat to life/limb; Abrupt change studies; DX endoscopies + risk
neuro status (seizure, TIA,
factors; Discography
weakness/sensory loss)
1 or less - Minimal ☐
2 – Limited ☐
3 – Multiple ☐
4 – Extensive ☐
B
1 or less - Minimal ☐
2 – Limited ☐
3 – Multiple ☐
4 – Extensive ☐
C
Minimal ☐
Low ☐
Moderate ☐
High ☐
SF
☐
Low
☐
Moderate
☐
High
☐
(choose column w/ 2-3
checks or center column)
New Office Visit or Consult (need 3 of 3)
☐ PF ☐ EPF
☐D
☐C
HISTORY
☐ PF ☐ EPF
☐D
☐C
EXAM
☐ SF
☐ SF
☐L
☐M
MDM
☐
1
☐
2
☐ Minor surgery + risk factors;
Elective major surgery;
Prescription drug
therapy/management;
Therapeutic nuclear medicine; IV
fluids + additives
☐ Elective major surg + risk
factors; Emergency major surg;
Parenteral controlled sub; Rx
requiring intense monitoring;
DNR or de-escalation of care
A
MDM Level
LEVEL
Management options
☐ Rest, gargle, elastic
bandages, superficial dressings
☐ OTC drugs; PT, OT; IV fluids
without additives; Minor surgery
NO risk factors
☐
3
☐
4
Time Based Billing (in minutes)
☐ 20
☐ 30
☐ 45
New Office ☐ 10
☐ 30
☐ 40
☐ 60
Off. Consult ☐ 15
☐C
☐C
☐H
☐
5
☐ 60
☐ 80
Established Office Visit (need 2 of 3)
☐ PF
☐ EPF
☐D
HISTORY
☐
☐
PF
☐
EPF
☐D
EXAM
Nurse
Visit
☐ SF
☐L
☐M
MDM
LEVEL
☐
1
☐
2
☐
3
☐
4
Time Based Billing (in minutes)
☐5
☐ 10
☐ 15
☐ 25
Est Office
☐C
☐C
☐H
☐
5
☐ 40
TIME: If ALL responses regarding time are "Yes," billing may be based on time.
*If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter,
time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment,
instructions, compliance, or risk education.

Does documentation reveal total face-to-face time? ☐ Yes ☐ No

Does documentation discuss the content of counseling or coordination of care? ☐ Yes ☐ No

Does documentation reveal that more than 50% of the time was spent on counseling or coordination of care? ☐ Yes ☐ No