Transcript evaluation and management audit form handout for chapter 2

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