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E and M Audit Forms M. Cremers - 2010 EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2 HISTORY – Part 2 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 3 Past Family and Social History (PFSH) _____ Past _____ Family _____ Social Patient response to questions asked by nurse, technician, or doctor Review of Systems (ROS) _____ Constitutional _____ Eyes _____ ENT _____CV _____ Respiratory _____ GI _____GU _____ MS _____ Integumentary _____ Neuro _____ Psych _____ Endocrine _____ Heme/Lymp _____ Allergic/Immun 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 (Parts 1, 2, 3) (read up and down) Type PF EP Detailed Comp Hx HPI 1-3 1-3 4+ 4+ ROS --1 2-9 10+ PFSH ----1 2-3 NOTE: For categories of Subsequent Hospital Care (99231-99233), Subsequent Nursing Facility Care (99307 – 99318) , Home Services for Established Patients (99334 – 99337, 99347 – 99350) CPT requires only an “interval history.” This means that it is not necessary to record information about the PFSH. EVALUATION AND MANAGEMENT AUDIT FORM HANDOUT FOR CHAPTER 2 Exam (Doctor physically examines the patient) Body Areas _____ Head _____ Neck _____Chest _____Abdomen _____Genitalia Organ Systems ____ Constitutional ____ Eyes ____ ENT ____ CV ____ Respiratory _____Back ____ GI ____ GU Eye Examination Components ____ M/S ____ Integum. ____ Neuro ____ Psych ____ Heme/ Lymph / Immun Base Exam ___VA ___IOP ___EOM ___VF Main Exam ___ A/C ___ Cornea ___ Pupils/Iris ___ Sclera ___ Conjunctiva DF ___ Retina ___ Macula ___ C/D Ratio _____Neuro: Orientation x 3 or Mood / Effect Each Extremity ___Left Arm ___ Left Leg ___ Right Arm ___ Right Leg 1995 Exam Components 1997 Exam Components (Used by most specialties unless Company Guidelines (Used by Ophthalmologic Practices unless stated otherwise) state otherwise) Type PF EP Detailed Comp Hx Body Areas / Organ Systems 1 2-4 5-7 8+ Type PF EP Detailed Comp Hx Body Areas / Organ Systems 2+ 6+ 9+ 13+ 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) Type Dx/Mgmt Data Risk SF 1 1 1 Low 2 2 2 Mod 3 High 4+ 3 4+ 3 4+ 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. Risk of Complications, Morbidity and/or Mortality 1 - 1 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 ______________ TOTAL Points ____________ OFFICE OR OTHER OUTPATIENT SERVICES NEW PATIENT (Location=Clinic) SVC HPI EXAM MDM OFFICE OR OTHER OUTPATIENT SERVICES ESTABLISHED PATIENT (Location=Clinic) TIME CODE SVC HPI EXAM MDM TIME CODE NEW NEW P E P E S S 10" 20" 99201 99202 EST EST P E P E S L 10" 15" 99212 99213 NEW NEW NEW D C C D C C L M H 30" 45" 60" 99203 99204 99205 EST EST D C D C M H 25" 40" 99214 99215 Requires 2 out of 3 components Nurses/techs use 99211 Coding Hint: Always throw out the lowest component Requires 3 out of 3 components Coding Hint: Always default to the lowest component CODE 99241 99242 99243 99244 99245 HOSPITAL INPATIENT SERVICES INPATIENT CONSULTATION (Initial Visit) (Location=Hospital Inpatient) SVC HPI EXAM MDM TIME CODE IC P P S 20" 99251 IC E E S 40" 99252 IC D D L 55" 99253 IC C C M 80" 99254 IC C C H 110" 99255 Requires 3 out of 3 components Coding Hint: Always default to the lowest component LEGEND For The HPI (History) and Exam (Examination) P=Problem-Focused E=Expanded Problem Focused D=Detailed C=Comprehensive NOTE: P may be abbreviated as PF E may be abbreviated as EP HOSPITAL INPATIENT SERVICES INITIAL HOSPITAL CARE (Location=Admitting) OFFICE OR OTHER OUTPATIENT CONSULTATIONS (Location=Clinic) SVC HPI EXAM MDM TIME NEW P P S 10" NEW E E S 20" NEW D D L 30" NEW C C M 45" NEW C C H 60" Requires 3 out of 3 components Never new or established patient Coding Hint: Always default to the lowest component Billing Based on Time - more than 50% of the time must be spent on counseling & coordination of care. HPI A A A HPI D-C C C EXAM MDM D-C S-L C M C H TIME 30" 50" 70" CODE 99221 99222 99223 Requires 3 out of 3 components Coding Hint: Always default to the lowest component HOSPITAL INPATIENT SERVICES SUBSEQUENT HOSPITAL CARE (Location=Hospital Inpatient) SVC HPI EXAM MDM TIME CODE IC P P S-l 15" 99231 IC E E M 25" 99232 IC D D H 35" 99233 IC = Inpatient Consult Requires 2 out of 3 components Coding Hint: Always throw out the lowest component LEGEND For the MDM S = Straight Forward L = Low Complexity M = Moderate Complexity H = High Complexity NOTE: If patient unresponsive, intubated, sedated, unconscious, HPI is always comprehensive If doctor lists the status of 3 chronic conditions, HPI is comprehensive Consult Verbage Advice, Opinion, Sent by, Requested by Render an opinion and/or recommendation For evaluation of, An Inquiry Asked to see __ regarding NOTE: This is not a complete list of questions that may be asked when interviewing a patient about present symptoms HPI - History of Present Illness Location Where is it? Place; whereabouts Timing How long does it last? How often does it come? Regulation of occurrence Quality What is it like? Word or words describing the symptoms, Characteristics; grade Content The setting in which it occurs, including environmental factors, personal activities, other circumstances when symptoms occurs. Circumstances in which a particular even occurs Severity How bad is it? How hard is it to endure? Duration Length of time since symptoms started? Length of time you've had the symptoms since going to see the doctor Modifying Factors Factors that alter the symptoms. Altering Elements; Condition May be something the patient is not aware of. Example - being sedentary Associated Signs & Symptoms Significantly related to the presenting problem. Other complaints the patient is having that may be connected to the CC or presenting problem ROS - Review of Systems Constitution Headache, fever, chills, malaise, fatigue, night sweats, weight loss or gain, appetite, sleep habits Eyes Visual acuity, blurring, diplopia, scotoma, itch, dryness, redness, infection, photophobia, pain, recent change in appearance or vision, glaucoma, use of eye drops or other eye medications, use of glasses or contact lenses, history of trauma or familial eye disease Ears, Nose, Throat (ENT) Hearing loss, pain, discharge, tinnitus, vertigo (dizziness), sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain, hoarseness or change in voice, swallowing, tonsillitis, lip lesions, canker sores, frequent sore throats, bleeding or swelling of gums, recent tooth abscesses or extractions, soreness of tongue or buccal mucosa, ulcers, disturbance of taste, glossitis, mucositis, Odynophagia (painful swallowing) Respiratory Pain related to respiration, dyspnea, asthma, pneumonia, pleurisy, cyanosis, wheezing, cough, character and quantity of sputum, hemoptysis, night sweats, exposure to TB, date and result of last chest x-ray examination Cardiovascular Chest pain or distress, precipitating causes, timing and duration, relieving factors, palpitations, murmur, dyspnea, orthopnea (number of pillows needed), history of rheumatic fever, phlebitis, varicosities, edema, claudication, hypertension, previous myocardial infarction, estimate of exercise tolerance, past EKG or other cardiac tests, peripheral vascular disease Endocrine Sugar/endo, diabetes, thyroid Integumentary Skin and/or breast, rash or eruption, itching, pigmentation or texture change, excessive sweating, moles, abnormal nail or hair growth, hives, tumors, sores, infections, diaphoresis, spider, angioma, malar rash (butterfly rash on the face), palmer erythema, pruritus, erythromelagia ROS - Review of Systems Continued Gastrointestinal Bowel, appetite, digestion, intolerance for any class of foods, dysphagia, heartburn, belching, nausea, vomiting, hematemesis, hematochezia, bloating, hernia, melena, abdominal pain, regularity of bowels, constipation, diarrhea, change in stool color or c Genirourinary Dysuria, flank or suprapublic pain, urgency, frequency, burning, nocturia, hematuria, polyuria, infection, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted disease Musculoskeletal Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity, cramps, weakness, atrophy, fracture, kyphosis, scoliosis, lordosis, back injury, Dupuytren's contracture, arthritis Hem/Lymph Blood disorders, cancer Neurological Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory, headache, vertigo, blindness, diplopia, pain, ataxia, dysethesia, tics, blackouts, numbness, tingling, lightheadedness (examination of sensation Psychiatric Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances, emotional instability, delusions, hallucinations, memory loss (orientation x 3) Allergic/Immuno Infections (recurrent), Allergies Past Personal, Medical, Family History - like the sheet you fill out when you go to the clinic Includes ocular meds & other meds, surgeries, other personal problems (ex. Diabetes, lupus, Past eye problems, heart problems, lung problems, breathing problems, etc) Family Any diseases/problems that run in the family Social Drinking, smoking, sexual activities, marital status, work status, drug use Exam Organ Systems Constitutional General appearance or condition, usual weight, recent weight changes, weakness, fatigue, fever, headaches, vitals (blood pressure, weight, Night sweats may be scored under the constitutional system or the respiratory system, depending on how it relates to the presenting problem Eyes Glaucoma, cataracts, color vision defects, decreased visual acuity, indescent vision, visual floaters, visual changes, eye discomfort, discharge, itching, spots, floaters, light sensitivity (photophobia), swelling, icterus ENT Ears - Loss of balance, ringing in the ears or tinnitus, poor hearing or deafness, ear pain or earaches (otalgia), infection, swelling ,discharge from ears dizziness or vertigo Nose - Nosebleeds, sinusitis or sinus trouble, breathing diffculties, frequent colds or sneezing, nasal discharge or stuffiness, hay fever, nose trauma Throat - difficulty swallowing, frequent sore throats, hoarseness Mouth - mouth sores, sore tongue, dry mouth, loss of taste, toothache, bleeding gums CV Respiratory GI (includes rectal) Chest pain (or no chest pain), palpitations, irregular heartbeats, heart murmurs, high blood pressure or hypertension, low blood pressure, edema or swelling (e.g. in ankles or hands), dyspnea, orthopnea or paroxysmal nocturnal dyspnea, varicose venis, leg pain when walking, coldness/numbness extremity, color changes with fingers or toes, hair loss, legs (PERTAINS TO CHEMO PATIENTS) - No peripheral cyanosis, clubbing or edema (deals with blood flow to the extremities) (looking for heart problems and enlarged joints), distal pulse, brutes Chronic cough, asthma, bronchitis, emphysema, pneumonia, turberculosis, pleurisy, hemoptysis, wheezing, sputum production No effusion or consolidation, no rubs or retractions, chest is clear to auscultation throughout NOTE: Night sweats may be scored under the constitutional system or the respiratory system depending on how it relates to the presenting problem, chest is grossly clear Indigestion, nausea or vomiting, vomiting of blood, loss of - change in - appetitie, heartburn, stomach or abdominal pain, excessive belching or passing of gas, diarrhea or constipation, bowel regularity (changes in color, ordor or consistency), rectal bleeding, black, tarry stools, food intolerance, hemorrhoids, liver or gall bladder trouble (including hepatitis or jaundice), hernia, hepatosplenomegaly Exam (Continued) Organ Systems GU NOTE: Some items involving breast tissue may also be placed under the integumentary system, depending on the nature of the presenting problem Integementary Skin Breast Both Genders - Patterns of urination, urine color, hx of renal calculi or flank pain, burning, difficulty or pain with urination (dysuria), blood in urine (hematuria), excessive urination (polyuria), times to the bathroom during the night (nocturia), incontinence, urgency, reduced urination, urinary infections, kidney stones Female Patients - Breast tenderness or pain, breast lumps, changes in breast contour, nipple discharge, birth control methods, age at menarche, regularity, frequency and/or duration of menstrual periods, painful menstration (dysmenorrhea), age at menopause, menopausal symptoms, frequency of and/or diffculties with sexual intercourse, vaginal discharge or itching, veneral disease, number of pregnancies Male Patients - Penile sores, penile discharge, testicular pain or masses, pain in breast tissue, lumps or change in the contour of breast tissue, hernias, frequency of and/or diffculties with sexual intercourse Rashes, Itching, Lumps or Lesions (new or changes), breast pain, nipple discharge or cramps Blood spots (petechiae), pigmentation abnormalities Moisture or dryness of skin Skin color (e.g. jaundice, cyanosis, pallor Skim temperature Growth and color of nails, changes in hair, nail color or texture Psychiatric Mood swings, anxiety, depression, inability to concentrate, inability to cope, nervousness, tnesion NOTE: Documentation that the patient feels tired a lot may fall under the pschiatric system, but may also fit into the endocrine system, depending on the nature of the presenting problem Description of patient's judgement & insight, orientation x 3, recent & remote memory, mood & affect Heme/Lymph Anemia, blood abmormalities, easy bruising or bleeding, blood transfusion, neck or groin swelling, nodules in the neck, low platelet count Palpatation of Lymph Nodes - Neck, Axillae, Groin, Other Exam (Continued) Organ Systems Musckuloskeletal Joints and Muscles, Difficulty in walking, sitting, or standing, limitations in walking Patient's balance on feet when standing, Back injuries or backache Arthritis, Gout, Muscle weakness, Cramps, Joint pains or stiffness Bone or muscle deformities, Osteo Allergic/Immuno Allergies including eczema, hives or itching, conjunctivitis Neurological Fainting, unconsciousness, blackouts, history of memory loss Seizures, hallucinations, tremors, headaches, disorientation Confusion, impaired mental status, paralysis, tremors speech or language dysfunction, local weakness Numbness or tingling sensations, Common Abbreviations Used By Doctors For the Physical Exam Portion of the Patient's Visit NC/AT - Normocephalic & traumatic (head not injured) JVD - Jugular Venous Distention (Neck) ND - Non-distended NT - Non-tender NABS - Normal active bowel sounds CP - Chest Pain NAD - No acute distree F/C - Fever, chills N/V - Nausea & vomiting # of Dx (diagnoses) or Mgmt of Prob Tests Ordered Level of Risk Points Self limiting or minor problem 1 Established/stable problem 1 Established worsening problem 2 New problem, no additional work up 3 New problem, needs add'l work up 4 Review and/or order radiology tests 1 Review and order other medical tests 1 Minimal Problem 1 Low Complexity 2 Moderate Complexity 3 High Complexity 4 Bone Scan - Nuclear Med Bone Density Study - 77078-77079 (Radiology Section of the CPT Book) PET Scan (Positron Emission Tomography) - 78608-78609, 78459, 78491-78492 (Radiology Section of the CPT Book) Thyroid Scan - can be nuclear/ radiological (78000;s) (Radiology Section of the CPT Book) Mammography - (Radiology Section of the CPT Book) MUGA (Multiple Gated Acquisition) Scan - nuclear medicine test to evaluate the function of the heart ventricles, 78472-78478, 78483 MRA (Magnetic Resonance Angiography) - (Radiology Section of the CPT Book) MRI (Magnetic Resonance Imaging) - (Radiology Section of the CPT Book) Diabetes - Endocrine Type I - children always on insulin Type II - adult onset, may or may not be on insulin