Em Audit Form PDF Details

The Em Audit Form represents a critical tool in the medical billing and coding process, ensuring that healthcare providers accurately document and bill for the services rendered to patients. By meticulously breaking down various components of a patient’s encounter, from the history of present illness to the complexity of medical decision-making, it aids in maintaining compliance and efficiency within medical practices. It comprises sections that cover the patient’s detailed medical history, including past illnesses, family and social history, and a comprehensive review of systems. Moreover, it extends to a thorough multi-system examination, ranging from constitutional symptoms to psychiatric evaluation, alongside categorizing the level of risk associated with the presented problems and proposed management options. This form not only assists in identifying under or over-coded services but also plays a pivotal role in optimizing revenue cycle management by ensuring coding accuracy and mitigating audit risks. The selection of the appropriate level of service based on the extent of the examination and the complexity of medical decision-making further underscores its significance in sustaining the financial viability of healthcare practices while adhering to coding standards and regulations.

QuestionAnswer
Form NameEm Audit Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaudit e m, em audit, 2021 e m audit tool, e m audit

Form Preview Example

Chart #: _____________E/M Audit Form

Patient Name: ___________________ Date of service: __ / /__ Provider: _________________ MR #: ______________________

Place of Service: ______________________ Service Type: ___________________ Insurance Carrier: ______________________

Code (s) selected: __________________Code(s) audited: ______________________

Over

Under

Correct

Miscoded

History

History of Present Illness

 

Review of Systems

Past, Family & Social History

 Location

 

 Constitutional symptoms

PAST MEDICAL

 Quality

 

 Eyes

 

 Current medication

 Severity

 

 Ears, nose, mouth, throat

 Prior illnesses and injuries

 Duration

 

 Cardiovascular

 Operations and hospitalizations

 Timing

 

 Respiratory

Age-appropriate immunizations

 Context

 

 Gastrointestinal

 Allergies  Dietary status

 Modifying factors

 

 Genitourinary

 

 Associated signs and symptoms

 Integumentary

FAMILY

 No. of chronic diseases

 Musculoskeletal

 

 

 

 Neurological

 Health status or cause of death of parents,

 

 

 Psychiatric

 

siblings, and children

 

 

 Endocrine

 

 Hereditary or high risk diseases

 

 

 Hematologic/lymphatic

 Diseases related to CC, HPI, ROS

 

 

 Allergic/immunologic

 

 

 

 

 

SOCIAL

 

 

 

 

 Living arrangements

PF=Brief HPI

 

 

 

 Marital status Sexual history

EPF=Brief HPI, ROS (Pertinent=1)

 

 

 

 Occupational history

Detailed= Extended HPI (4+) + ROS=(2-9) PFSH=1

 

 

 Use of drugs, alcohol, or tobacco

Comprehensive= Extended HPI + ROS (10 + systems) PFSH=2 Established, 3 New Patient

 Extent of education

PFSH Form reviewed, no change

PFSH form reviewed, updated

PFSH form new

 Current employment Other

**Extended HPI=Status of 3 chronic illnesses with 1997 DG. Some allow for 1995 as well.

History ______________

 

 

General Multi-System Examination

 

 

Constitutional

3 of 7 (BP,pulse,respir,tmp,hgt,wgt)

General Appearance

Eyes

Conjunctivae, Lids

Eyes: Pupils, Irises

Ophthal exam -Optic discs, Pos Seg

ENT

Ears, Nose

Oto exam -Aud canals,Tymp membr

Hearing

Nasal mucosa, Septum, Turbinates

ENTM: Lips, Teeth, Gums

Oropharynx -oral mucosa,palates

Neck

Neck

Thyroid

Respiratory

Respiratory effort

Percussion of chest

Palpation of chest

Auscultation of lungs

Cardiovascular

Palpation of heart

Auscultation of heart (& sounds)

Carotid arteries

Abdominal aorta

Femoral arteries

Pedal pulses

Extrem for periph edema/varicoscities

Chest

Inspect Breasts

Palpation of Breasts & Axillae

Gastrointestinal

Abd (+/- masses or tenderness)

Liver, Spleen

Hernia (+/-)

Anus, Perineum, Rectum

Stool for occult blood

GU/Female

Female: Genitalia, Vagina

Female Urethra

Bladder

Cervix

Uterus

Adnexa/parametria

GU/Male

Scrotal Contents

Penis

Digital rectal of Prostate

Lymphatic

Lymph: Neck

Lymph: Axillae

Lymph: Groin

Lymph: Other

Musculoskeletal

Gait (...ability to exercise)

Palpation Digits, Nails

Head/Neck: Inspect, Palp

Head/Neck: Motion (+/-pain,crepit)

Head/Neck: Stability (+/- lux,sublux)

Head/Neck: Muscle strength & tone

Spine/Rib/Pelv: Inspect, Palp

Spine/Rib/Pelv: Motion

Spine/Rib/Pelv: Stability

Spine/Rib/Pelv: Strength and tone

R.Up Extrem: Inspect, Palp

R.Up Extrem: Motion (+/- pain, crepit)

R.Up Extrem: Stability (+/- lux, sublux)

R.Up Extrem: Muscle strength & tone

L.Up Extrem: Inspect, Palp

L.Up Extrem: Motion (+/- pain, crepit)

L.Up Extrem: Muscle strength & tone

R.Low Extrem: Inspect, Palp

R.Low Extrem: Motion (+/-pain, crepit)

R.Low Extrem: Stability (+/- lux, laxity)

R.Low Extrem: Muscle strength & tone

L.Low Extrem: Inspect, Palp

L.Low Extrem: Motion (+/-pain, crepit)

L.Low Extrem: Stability (+/- lux, sublux)

L.Low Extrem: Muscle strength & tone

Skin

Skin: Inspect Skin & Subcut tissues

Skin: Palpation Skin & Subcut tissues

Neuro

Neuro: Cranial nerves (+/- deficits)

Neuro: DTRs (+/- pathological reflexes)

Neuro: Sensations

Psychiatry

Psych: Judgement, Insight

Psych: Orientation time, place, person

Psych: Recent, Remote memory

Psych: Mood, Affect (depression, anxiety)

Exam: ______________________

1995-1=PF, limited 2-7=EPF, extended

2-7=Detailed, 8+ organ systems=Comprehensive 1997-1-5=PF, 6-11=EPF, 2x6 systems=D

2 from 9 systems=Comp.

 

 

Number of

Points

 

 

 

Diagnoses/Management Options

 

 

 

 

 

 

 

 

 

Self-limited or minor (Stable,

1

 

 

 

improved or worsening) 

 

 

 

 

Maximum 2 points in this

 

 

 

 

category.

 

 

 

 

 

 

 

 

 

Established problem (to

1

 

 

 

examining MD); stable or

 

 

 

 

improved

 

 

 

 

 

 

 

 

 

Established problem (to

2

 

 

 

examining MD); worsening

 

 

 

 

 

 

 

 

 

New problem (to examining MD);

3

 

 

 

no additional work-up planned 

 

 

 

 

 

 

 

 

 

New problem (to examining MD);

4

 

 

 

additional work-up (e.g.

 

 

 

 

admit/transfer)

 

 

 

 

 

 

 

 

 

Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount and/or Complexity of Data

 

Points

 

 

Reviewed

 

 

 

 

 

 

 

 

Lab ordered and/or reviewed (regardless of #

1

 

 

ordered)

 

 

TABLE OF RISK

Level of

Presenting Problem(s)

Diagnostic Procedure(s)

Management Options

Risk

 

Ordered

Selected

 

 

 

 

 

•One self-limited or minor problem, eg,

• Laboratory tests requiring

• Rest

 

cold, insect bite, tinea corporis

venipuncture

• Gargles

 

 

• Chest x-rays

• Elastic bandages

 

 

• EKG/EEG

• Superficial dressings

 

 

• Urinalysis

 

 

 

• Ultrasound, eg, echocardiography

 

Minimal

 

• KOH prep

 

 

 

 

 

 

• Two or more self-limited or minor

• Physiologic tests not under stress, eg,

Over-the-counter drugs

 

problems

pulmonary function tests

• Minor surgery with no identified risk

 

• One stable chronic illness, eg, well

Non-cardiovascular imaging studies

factors

 

controlled hypertension, non-insulin

with contrast, eg, barium enema

• Physical therapy

 

dependent diabetes, cataract, BPH

• Superficial needle biopsies

• Occupational therapy

 

• Acute uncomplicated illness or injury,

• Clinical laboratory tests requiring

• IV fluids without additives

 

eg, cystitis, allergic rhinitis, simple

arterial puncture

 

Low

sprain

• Skin biopsies

 

 

 

 

 

 

• One or more chronic illnesses with

• Physiologic tests under stress, eg,

• Minor surgery with identified risk factors

 

mild exacerbation, progression, or side

cardiac stress test, fetal contraction

• Elective major surgery (open,

 

effects of treatment

stress test

percutaneous or endoscopic) with no

 

• Two or more stable chronic illnesses

• Diagnostic endoscopies with no

identified risk factors

 

• Undiagnosed new problem with

identified risk factors

• Prescription drug management

 

uncertain prognosis, eg, lump in breast

• Deep needle or incisional biopsy

• Therapeutic nuclear medicine

 

• Acute illness with systemic symptoms,

• Cardiovascular imaging studies with

• IV fluids with additives

 

eg, pyelonephritis, pneumonitis, colitis

contrast and no identified risk factors,

• Closed treatment of fracture or dislocation

 

• Acute complicated injury, eg, head

eg, arteriogram, cardiac

without manipulation

 

injury with brief loss of consciousness

catheterization

 

 

 

• Obtain fluid from body cavity, eg

 

 

 

lumbar puncture, thoracentesis,

 

Moderate

 

culdocentesis

 

 

 

 

 

 

 

 

 

X-ray ordered and/or reviewed (regardless of #

1

 

ordered)

 

 

 

 

 

Medicine section (90701-99199) ordered

1

 

and/or reviewed

 

 

 

 

 

Discussion of test results with performing

1

 

physician

 

 

 

 

 

Decision to obtain old record and/or obtain hx

1

 

from someone other than patient

 

 

 

 

 

Review and summary of old records and/or

 

 

obtaining hx from someone other than patient

2

 

and/or discussion with other health provider

 

 

 

 

 

Independent visualization of image, tracing, or

2

 

specimen (not simply review of report)

 

 

 

 

 

Total

 

 

 

 

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, eg, 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, eg, seizure, TIA, weakness, 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

Medical Decision Making

Number of Diagnoses or Treatment Options

Amount and/or Complexity of Data to be Reviewed

Risk of Complications, Morbidity, Mortality

MDM Level=2 out of 3

SF

1

1

Minimal

LOW

2

2

Low

MOD

3

3

Moderate

HIGH

4

4

High

MDM ______________

Chart Note

Comments

Dictated

Handwritten

Form

Illegible

Note signed

Signature missing

Other Services or Modalities:

Auditor’s Signature

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2021 e m audit tool empty fields to complete

Put the required information in the Review of Systems Constitutional, PFBrief HPI EPFBrief HPI ROS, PFSH Form reviewed no change, PFSH form reviewed updated, PFSH form new, Extended HPIStatus of chronic, Health status or cause of death, siblings and children, Hereditary or high risk diseases, SOCIAL, Living arrangements Marital, Constitutional of, General MultiSystem Examination, Gastrointestinal Abd masses or, and RUp Extrem Motion pain crepit section.

Filling out 2021 e m audit tool part 2

It is vital to put down certain particulars in the space Constitutional of, Gastrointestinal Abd masses or, RUp Extrem Motion pain crepit, Exam, and PF limited EPF extended Detailed.

Filling out 2021 e m audit tool stage 3

The LOW, MOD, HIGH, MDM, Minimal, Low, Moderate, High, Medical Decision Making Number of, Chart Note, Comments, Dictated Form Note signed, Handwritten Illegible, Other Services or Modalities, and Auditors Signature section has to be applied to note the rights or responsibilities of both parties.

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