Practical E/M Audit Form: Initial Outpatient Visit (p.1)

Transcription

1 Patient: Name: Chart #: Date of visit: / / Reviewed by: Date of review: / / Practical E/M Audit Form: Initial Outpatient Visit (p.1) Medical History Review Select the level corresponding to lowest of the components PFSH ROS HPI Level of History 5 3 elements 10 or more 4-8 elements, or Comprehensive Related 4 status of > 3 chronics E/M level: 3 1 element 2-9 syst Detailed 2 0 elements 1 system 1-3 elements Expanded 1 0 systems or no chronology Prob focused no HPI no history Chronology Fails to document or clearly reflect a chief complaint Duration Fails to document supplemental details of positive findings for PFSH Timing Fails to document supplemental details of positive findings for ROS Severity Fails to document chronological details of HPI (performing only an "extended" Chief Complaint) Location Fails to document the STATUS of at least 3 chronic or inactive conditions Quality *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed Context Copy forward functionality Copy-paste of pre-loaded generic text Mod. factors Documentation by exception, automated or single click Assoc signs & Sx Non-specific documentation resulting from use of pick lists Physical Exam Review (1997 Guidelines) Select the level corresponding to guideline description multi-system specialty Ophth & Psych Level of Exam 5 2 in each of all major, one all major, one Comprehensive Related 4 9 systems in each minor in each minor E/M level: 3 12 elements 12 elements 9 elements Detailed elements 6-11 elements 6-8 elements Expanded elements 1-5 elements 1-5 elements Prob focused Fails to document specific abnormal findings no exam Fails to document relevant negative findings of symptomatic organ systems *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed Copy forward functionality Copy-paste of pre-loaded generic text Documentation by exception, automated or single click Non-specific documentation resulting from use of pick lists Physical Exam Review (1995 Guidelines) Select the level corresponding to guideline description Level of Exam Related organ systems or complete single organ system exam Comprehensive E/M level: 3 Extended exam of affected & related areas/systems Detailed 2 Limited exam of affected & related areas/systems Expanded 1 Limited exam of affected body area or organ system Prob focused Fails to document specific abnormal findings no exam Fails to document relevant negative findings of symptomatic organ systems *EHR documentation compliance issues fail to validate medical necessity &/or that care was performed Copy forward functionality Copy-paste of pre-loaded generic text Documentation by exception, automated or single click Non-specific documentation resulting from use of pick lists

2 Instructions for Page 1 Instructions, Medical History Section: 1) Circle the number of documented elements of the PFSH; 2) Circle the range containing the number of documented elements of the ROS; 3) Circle the range containing the number of elements of the HPI documented on page 1 Be sure to indicate if these elements include a "chronological description of course of illness" 4) Review the four boxes evaluating the qualitative Documentation Guidelines of the Medical History Document any qualitative features not completed and adjust the quantitative values circled if indicated 5) Review the four boxes evaluating possible non-compliant data entry functions by an EHR (or dictation) Document any non-compliant data entry functions and adjust the quantitative values circled if indicated 6) Then circle the Level of History that corresponds to the lowest of the three key components circled 7) Transfer this Level of History to the Level of History column on page 5 Instructions, Physical Examination Section: A) 1997 Documentation Guidelines 1) Select the column for the type of examination documented: general multi-system examination, one of the 11 specialty specific examinations other than opthalmology or psychiatry, or ophthalmology or psychiatry 2) Circle the range containing the number of documented examination elements in the appropriate column 3) Review the two boxes evaluating the qualitative Documentation Guidelines of the Physical Examination Document any qualitative features not completed and adjust the quantitative values circled if indicated 4) Review the four boxes evaluating possible non-compliant data entry functions by an EHR (or dictation) Document any non-compliant data entry functions and adjust the quantitative values circled if indicated 5) Circle the Level of Exam that corresponds to this number of exam elements B) 1995 Documentation Guidelines (if indicated) 1) Circle the appropriate level of examination documented; note that "extended" applies to all organ systems and that all systems potentially related to the presenting problem(s) should be examined and documented 2) Circle the Level of Exam that correspondes to this description 3) Review the two boxes evaluating the qualitative Documentation Guidelines of the Physical Examination Document any qualitative features not completed and adjust the quantitative values circled if indicated 4) Review the four boxes evaluating possible non-compliant data entry functions by an EHR (or dictation) Document any non-compliant data entry functions and adjust the quantitative values circled if indicated C) Transfer the higher of these two Levels of Exam to the Level of Exam column on page 5

3 Section 1: Medical History HPI: see color sheet for listing of chronologic description & 8 elements of HPI PFHS: record which elements have documented inquiries & responses (see color sheet for documentation of qualitative factors & EHR data entry issues) Past medical history Family history Social history Number of elements documented ROS: record which organ systems have documented inquiries & responses (see color sheet for documentation of qualitative factors & EHR data entry issues) Constitutional Gastrointestinal Neurological Eyes Genitourinary Psychiatric Ears, nose, & throat Cardiovascular Musculoskeletal Integumentary Endocrine Hematologic/lymphatic Respiratory (skin and/or breast) Allergic/immunologic Section 2: Physical Examination 1997 Documentation Guidelines: Types of Examinations: Number of organ systems documented General multi-system exam Genitourinary (female) Cardiovascular Genitourinary (male) Psychiatric Ears, nose, & throat Eyes Hematologic/lymphatic/immunologic Musculoskeletal Respiratory Skin Neurological see exam details in "Documentation Guidelines for Evaluation & Management Coding" to identify number of designated exam elements documented 1995 Documentation Guidelines: Data Gathering Form, History & Exam (p.1b) Body areas: Head and face Abdomen Back, including spine Neck Genitalia, groin, buttocks Chest, incl. breasts & axillae Each extremity Organ systems: Constitutional Respiratory Skin Eyes Ears, nose, mouth, throat Gastroinstestinal Genitourinary Neurological Psychiatric Cardiovascular Musculoskeletal Hematol/lymph/immunol Documentation Details: All other symptomatic or related organ systems documented All other symptomatic or related organ systems NOT documented LIMITED examination of (all) affected and symptomatic/related organ systems (includes cases with less than an extended exam of ALL affected & related organ systems) EXTENDED examination of (all) affected and symptomatic/related organ systems COMPLETE examination of a single organ system

4 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Initial Outpatient Visit (p.2) Medical Decision Making (MDM) Select the 2nd lowest of the RED circled levels Dx or Rx Options Data Reviewed & Ordered Levels of Risk Level of MDM 5 ext 4 ext 4 ext 4 ext ext 4 ext high high high High Related 4 mult 3 mult 3 mod3 mod mod 3 mod mod mod mod Mod E/M level: 3 lim 2 lim 2 lim 2 lim lim 2 lim low low low Low 2 min 1 min 1 min 0-1 min min 0-1 min min min min Strtfrwd 1 cmplx cmplx pres diag mgmt no MDM Dx Rx # rev rev # ord ord probs proc optns Circle highest in red Circle highest of 4 in red Circle highest of 3 in red * Indicates sub-component(s) of MDM that were not documented in the medical record 1) Level of each MDM component is circled in blue or black ink, whether documented or interpreted by reviewer 2) Highest level in each of the three sections is circled in red ink; 3) An asterisk within the circle of any sub-component indicates that it was not documented in the medical record 4) The calculated level of MDM corresponds to the 2nd lowest of the red circles, which appears in the final column Glossary: Dx or Rx Options Dx: number of diagnoses Rx: number of treatment options min: minimum lim: limited mult: multiple ext: extensive Data Reviewed & Ordered # rev: amount of data reviewed min: minimum cmplx rev: complexity of data reviewed lim: limited # ord: amount of data ordered mod: moderate cmplx ord: complexity of data ordered ext: extensive Levels of Risk pres probs: risk of the presenting problem(s) diag proc: risk of the diagnostic procedures mgmt optns: risk of the management options min: minimum low: low mod: moderate high: high

5 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Initial Outpatient Visit (p.3) Nature of the Presenting Problem(s) Moderate-High or High Code Level Warranted by NPP 5 Moderate-High 4 Moderate Low-Moderate Low Minor * Indicates severity of NPP is not documented in the medical record 1) Circles indicate severity of NPP and level of code warranted by this degree of severity 2) If severity of NPP not documented in medical record, level of severity and corresponding level of warranted care seem appropriate based on remaining documentation; indicated by asterisk (*) 3) If appropriate severity seems to be "moderate to high," choice of code level 4 or 5 based on level of care suggested as appropriate by the examples in CPT's Appendix C and/or highest documented level of risk CPT Descriptors for Severity of NPP: (* intermediate descriptors interpreted by Practical E/M) Minor: Problem runs definite and prescribed course, is tansient in nature, and is not likely to permanently alter health status; OR, has a good prognosis with management and compliance Low: Problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected Low - Mod: *Problem where the risk of morbidity without treatment is low to moderate; there is low to moderate risk of mortality without treatment; full recovery without functional impairment is expected in most cases, with low probability of prolonged functional impairment Moderate: Problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; prognosis is uncertain, or there is an increased probability of prolonged functional impairment. Mod - High: *Problem where the risk of morbidity without treatment is moderate to high; there is moderate risk of mortality without treatment; uncertain prognosis or increased probability of prolonged functional impairment High: Problem where the risk of morbidity without treatment is high to extreme; there is moderate to high risk of mortality without treatment, or high probability of severe prolonged functional impairment.

6 Patient: Name: Chart #: Date of visit: / / Practical E/M Audit Form: Time for Counseling / Coordination of Care (p. 4) Initial Outpatient Visit Time for Counseling / Coordination of Care DOCUMENTATION that > 50% of face-to-face time spent counseling and/or coorinating care DOCUMENTATION of total amount of FACE-TO-FACE time of visit DOCUMENTATION of counseling and/or coordination performed Initial Visit Code Level Indicated by Time 60 mins mins mins mins mins ) Time considered for code selection ONLY if ALL THREE of the above boxes are checked 2) Time value selected must equal or exceed amount in selected box

7 Patient: Name: Chart #: Date of visit: / / CPT Compliant E/M Audit Tools: Initial Outpatient Visit (Summary) Select Correct E/M Code Code Level Code Level Code Level by Key Warranted Indicated Select the level corresponding to the lowest component Components by NPP by Time Comprehensive Comprehensive High Moderate Detailed Detailed Low Expanded Expanded Strtfrwd Prob focused Prob focused no history no exam no MDM N/A Level of Level of Level of History Exam MDM 1) "Level of history" is value that was determined on page 1 2) "Level of exam" is value that was determined on page 1; selected the higher of 1995 or 1997 Guidelines 3) "Level of MDM" is value that was determined on page 2 4) "Code level by key components" is indicated by the lowest level circled among the 3 key components If the medical record lacks documentation of history, examination, or MDM, then, by CPT definition, an E/M service was not performed; claim for E/M service should be denied 5) "Code level warranted by NPP" is value that was determined on page 3 6) "Code level indicated by Time" is value that was determined on page 4 (if time properly documented) 7) The result of step 4 indicates the level of care performed and documented; The result of step 5 indicates the level of care that is medically necessary / indicated The result of step 6 indicates the level of care that is supported by time of counseling and coordination of care Usually, the code level warranted by the NPP establishes the maximum level of care that should be coded If time properly documented, code level determined by time supercedes key components & NPP if it was higher Conclusion: code submitted: Code medically indicated based on NPP: Level of care documented: Code level based on counseling & time: N/A