School-Based Health Alliance
PATIENT IDENTIFIER__________
CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
Preventive Health – New patient ______
Preventive Health – Established patient ______
Counseling Services– No Physical Complaint
Is time recorded in chart? YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit: where counseling determines time
Is the total time of the visit recorded YES _____ NO _____
Is the time spent in counseling recorded YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit – NEW PATIENT
Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES ______ ICDE-9 CODES DO THE CPT/ICD-9 CODES
COORELATE? Would you get paid?
YES NO _____
HISTORY AND EXAMINATION
|New | 99201** |99202 |99203 |99204 |99205 |
|Established |99201 |99212 |99213 |99214 |99215 |
|HPI |0 |1 |1 |4 |4* |
|ROS |0 |0 |1 |2 |10 |
|PFSH |0 |0 |0 |1 |2 |
|EXAM |0 |1 |4 |5 |8 |
* or status of at least 3 chronic or inactive conditions
CHART AUDIT LEVELS FOR E/M VISITS - . CPT code correct for chart documentation?
HPI, ROS, PFSH NEW PATIENT LEVEL ____
NEW PATIENTS: ALL Three are required – lowest level determines
EXAMINATION _____
ESTABLISHED PT LEVEL ____
ESTABLISHED PATIENTS: Two out of Three determines level
MEDICAL DECISION MAKING* 3
(Determine this first)
*See next page
MEDICAL DECISION MAKING – Determine this level first, then verify that chart
documentation (HPI, ROS, PFSH & Examination) supports the level
Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level.
|New |99201* |99202 |99203 |99204 |99205[1] |
|Established |99211 |99212 |99213 |99214 |99215 |
|Diagnoses or Management| |-One Self-limited or |-Two or more self-limited |-One or more chronic illnesses |-One or more chronic illness |
|Problems | |minor problem |or minor problems |with complications |with severe complications |
| | | |-One stable chronic |-Two or more stable chronic |-Acute or chronic illness or |
| | | |condition |illnesses |injury that is life or limb |
| | | |-Acute uncomplicated |-Undiagnosed new prob. w/ |threatening |
| | | |illness (e.g., allergic |uncertain prognosis |-Abrupt change in neurologic |
| | | |rhinitis, simple sprain |-Acute illness with systemic |status |
| | | | |symptoms | |
| | | | |Acute complicated injury | |
|Diagnostic Procedures | |-Lab |-Physiologic tests not |-Physiologic tests under stress|-Cardiovascular imaging with |
|(only 2 areas must | |-X-ray |under stress |- cardiac stress test |contrast |
|agree to determine | |-EKG |-Pulmonary Function |-Diagnostic endoscopies with no|Invasive diagnostic tests |
|medical decision making| |-UA |-Barium enema |risk factors |-Cardiac electrophysiological|
|level, so this area is | |-Ultrasound |-Arterial puncture |-Deep needle or incisional |tests |
|not usually the deal | |-Venipuncture |-Skin biopsies |biopsy |-Diagnostic endoscopies w/ |
|breaker as most SBHC | |-KOH. | |-Obtained fluid from body |identified risk factors |
|do not typically do | | | |-Cardiovascular imaging w/ |-Discography |
|level 3, 4 or 5 | | | |contrast | |
|Diagnostics) | | | | | |
|Treatment of Management| |-Rest |-OTCs |-Minor surgery with risk |-Elective surgery with |
|Options | |-Gargles |-Minor surgery w/ no |factors |identified risk factors |
| | |-Elastic bandages |identified risk factors |-Elective major surgery - no |-Emergency major surgery |
| | |-Dressings |-PT |risk factors |-Parenteral controlled |
| | | |-OT |-Prescription drug management |substances |
| | | |-IVs without additives |-IV fluids with additives |-Drug treatment requiring |
| | | | |-Closed fracture or dislocation|intense monitoring |
| | | | |treatment w/o manipulation |-Decisions not to resuscitate|
| | | | |-Therapeutic nuclear medicine |or de-escalate care because |
| | | | | |of poor prognosis |
PATIENT IDENTIFIER__________
CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
Preventive Health – New patient ______
Preventive Health – Established patient ______
Counseling Services– No Physical Complaint
Is time recorded in chart? YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit: where counseling determines time
Is the total time of the visit recorded YES _____ NO _____
Is the time spent in counseling recorded YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit – NEW PATIENT
Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES ______ ICDE-9 CODES __ DO THE CPT/ICD-9 CODES
COORELATE? Would you get paid?
YES NO ____
HISTORY AND EXAMINATION
|New | 99201** |99202 |99203 |99204 |99205 |
|Established |99201 |99212 |99213 |99214 |99215 |
|HPI |0 |1 |1 |4 |4* |
|ROS |0 |0 |1 |2 |10 |
|PFSH |0 |0 |0 |1 |2 |
|EXAM |0 |1 |4 |5 |8 |
* or status of at least 3 chronic or inactive conditions
CHART AUDIT LEVELS FOR E/M VISITS
HPI, ROS, PFSH NEW PATIENT LEVEL ____
NEW PATIENTS: ALL Three are required – lowest level determines
EXAMINATION _____
ESTABLISHED PT LEVEL ____
ESTABLISHED PATIENTS: Two out of Three determines level
MEDICAL DECISION MAKING*
(Determine this first)
*See next page
MEDICAL DECISION MAKING – Determine this level first, then verify that chart
documentation (HPI, ROS, PFSH & Examination) supports the level
Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level.
|New |99201* |99202 |99203 |99204 |99205[2] |
|Established |99211 |99212 |99213 |99214 |99215 |
|Diagnoses or Management| |-One Self-limited or |-Two or more self-limited |-One or more chronic illnesses |-One or more chronic illness |
|Problems | |minor problem |or minor problems |with complications |with severe complications |
| | | |-One stable chronic |-Two or more stable chronic |-Acute or chronic illness or |
| | | |condition |illnesses |injury that is life or limb |
| | | |-Acute uncomplicated |-Undiagnosed new prob. w/ |threatening |
| | | |illness (e.g., allergic |uncertain prognosis |-Abrupt change in neurologic |
| | | |rhinitis, simple sprain |-Acute illness with systemic |status |
| | | | |symptoms | |
| | | | |Acute complicated injury | |
|Diagnostic Procedures | |-Lab |-Physiologic tests not |-Physiologic tests under stress|-Cardiovascular imaging with |
|(only 2 areas must | |-X-ray |under stress |- cardiac stress test |contrast |
|agree to determine | |-EKG |-Pulmonary Function |-Diagnostic endoscopies with no|Invasive diagnostic tests |
|medical decision making| |-UA |-Barium enema |risk factors |-Cardiac electrophysiological|
|level, so this area is | |-Ultrasound |-Arterial puncture |-Deep needle or incisional |tests |
|not usually the deal | |-Venipuncture |-Skin biopsies |biopsy |-Diagnostic endoscopies w/ |
|breaker as most SBHC | |-KOH. | |-Obtained fluid from body |identified risk factors |
|do not typically do | | | |-Cardiovascular imaging w/ |-Discography |
|level 3, 4 or 5 | | | |contrast | |
|Diagnostics) | | | | | |
|Treatment of Management| |-Rest |-OTCs |-Minor surgery with risk |-Elective surgery with |
|Options | |-Gargles |-Minor surgery w/ no |factors |identified risk factors |
| | |-Elastic bandages |identified risk factors |-Elective major surgery - no |-Emergency major surgery |
| | |-Dressings |-PT |risk factors |-Parenteral controlled |
| | | |-OT |-Prescription drug management |substances |
| | | |-IVs without additives |-IV fluids with additives |-Drug treatment requiring |
| | | | |-Closed fracture or dislocation|intense monitoring |
| | | | |treatment w/o manipulation |-Decisions not to resuscitate|
| | | | |-Therapeutic nuclear medicine |or de-escalate care because |
| | | | | |of poor prognosis |
PATIENT IDENTIFIER__________
CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
Preventive Health – New patient ______
Preventive Health – Established patient ______
Counseling Services– No Physical Complaint
Is time recorded in chart? YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit: where counseling determines time
Is the total time of the visit recorded YES _____ NO _____
Is the time spent in counseling recorded YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit – NEW PATIENT
Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES ______ ICDE-9 CODES DO THE CPT/ICD-9 CODES
COORELATE? Would you get paid?
YES NO ____
HISTORY AND EXAMINATION
|New | 99201** |99202 |99203 |99204 |99205 |
|Established |99201 |99212 |99213 |99214 |99215 |
|HPI |0 |1 |1 |4 |4* |
|ROS |0 |0 |1 |2 |10 |
|PFSH |0 |0 |0 |1 |2 |
|EXAM |0 |1 |4 |5 |8 |
* or status of at least 3 chronic or inactive conditions
CHART AUDIT LEVELS FOR E/M VISITS
HPI, ROS, PFSH NEW PATIENT LEVEL ____
NEW PATIENTS: ALL Three are required – lowest level determines
EXAMINATION _____
ESTABLISHED PT LEVEL ____
ESTABLISHED PATIENTS: Two out of Three determines level
MEDICAL DECISION MAKING* 3
(Determine this first)
*See next page
MEDICAL DECISION MAKING – Determine this level first, then verify that chart
documentation (HPI, ROS, PFSH & Examination) supports the level
Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level.
|New |99201* |99202 |99203 |99204 |99205[3] |
|Established |99211 |99212 |99213 |99214 |99215 |
|Diagnoses or Management| |-One Self-limited or |-Two or more self-limited |-One or more chronic illnesses |-One or more chronic illness |
|Problems | |minor problem |or minor problems |with complications |with severe complications |
| | | |-One stable chronic |-Two or more stable chronic |-Acute or chronic illness or |
| | | |condition |illnesses |injury that is life or limb |
| | | |-Acute uncomplicated |-Undiagnosed new prob. w/ |threatening |
| | | |illness (e.g., allergic |uncertain prognosis |-Abrupt change in neurologic |
| | | |rhinitis, simple sprain |-Acute illness with systemic |status |
| | | | |symptoms | |
| | | | |Acute complicated injury | |
|Diagnostic Procedures | |-Lab |-Physiologic tests not |-Physiologic tests under stress|-Cardiovascular imaging with |
|(only 2 areas must | |-X-ray |under stress |- cardiac stress test |contrast |
|agree to determine | |-EKG |-Pulmonary Function |-Diagnostic endoscopies with no|Invasive diagnostic tests |
|medical decision making| |-UA |-Barium enema |risk factors |-Cardiac electrophysiological|
|level, so this area is | |-Ultrasound |-Arterial puncture |-Deep needle or incisional |tests |
|not usually the deal | |-Venipuncture |-Skin biopsies |biopsy |-Diagnostic endoscopies w/ |
|breaker as most SBHC | |-KOH. | |-Obtained fluid from body |identified risk factors |
|do not typically do | | | |-Cardiovascular imaging w/ |-Discography |
|level 3, 4 or 5 | | | |contrast | |
|Diagnostics) | | | | | |
|Treatment of Management| |-Rest |-OTCs |-Minor surgery with risk |-Elective surgery with |
|Options | |-Gargles |-Minor surgery w/ no |factors |identified risk factors |
| | |-Elastic bandages |identified risk factors |-Elective major surgery - no |-Emergency major surgery |
| | |-Dressings |-PT |risk factors |-Parenteral controlled |
| | | |-OT |-Prescription drug management |substances |
| | | |-IVs without additives |-IV fluids with additives |-Drug treatment requiring |
| | | | |-Closed fracture or dislocation|intense monitoring |
| | | | |treatment w/o manipulation |-Decisions not to resuscitate|
| | | | |-Therapeutic nuclear medicine |or de-escalate care because |
| | | | | |of poor prognosis |
PATIENT IDENTIFIER__________
CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
Preventive Health – New patient ______
Preventive Health – Established patient ______
Counseling Services– No Physical Complaint
Is time recorded in chart? YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit: where counseling determines time
Is the total time of the visit recorded YES _____ NO _____
Is the time spent in counseling recorded YES _____ NO _____
Is a counseling code used? YES _____ NO _____
Evaluation / Management Visit – NEW PATIENT
Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES ______ ICDE-9 CODES __ DO THE CPT/ICD-9 CODES
COORELATE? Would you get paid?
______ ______
YES _____ NO ______
______ ______
HISTORY AND EXAMINATION – This section does not apply for preventive visit
|New | 99201** |99202 |99203 |99204 |99205 |
|Established |99201 |99212 |99213 |99214 |99215 |
|HPI |0 |1 |1 |4 |4* |
|ROS |0 |0 |1 |2 |10 |
|PFSH |0 |0 |0 |1 |2 |
|EXAM |0 |1 |4 |5 |8 |
* or status of at least 3 chronic or inactive conditions
CHART AUDIT LEVELS FOR E/M VISITS
HPI, ROS, PFSH _____ NEW PATIENT LEVEL ____
NEW PATIENTS: ALL Three are required – lowest level determines
EXAMINATION _____
ESTABLISHED PT LEVEL ____
ESTABLISHED PATIENTS: Two out of Three determines level
MEDICAL DECISION MAKING* _____
(Determine this first)
*See next page
MEDICAL DECISION MAKING – Determine this level first, then verify that chart
documentation (HPI, ROS, PFSH & Examination) supports the level
Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level.
|New |99201* |99202 |99203 |99204 |99205[4] |
|Established |99211 |99212 |99213 |99214 |99215 |
|Diagnoses or Management| |-One Self-limited or |-Two or more self-limited |-One or more chronic illnesses |-One or more chronic illness |
|Problems | |minor problem |or minor problems |with complications |with severe complications |
| | | |-One stable chronic |-Two or more stable chronic |-Acute or chronic illness or |
| | | |condition |illnesses |injury that is life or limb |
| | | |-Acute uncomplicated |-Undiagnosed new prob. w/ |threatening |
| | | |illness (e.g., allergic |uncertain prognosis |-Abrupt change in neurologic |
| | | |rhinitis, simple sprain |-Acute illness with systemic |status |
| | | | |symptoms | |
| | | | |Acute complicated injury | |
|Diagnostic Procedures | |-Lab |-Physiologic tests not |-Physiologic tests under stress|-Cardiovascular imaging with |
|(only 2 areas must | |-X-ray |under stress |- cardiac stress test |contrast |
|agree to determine | |-EKG |-Pulmonary Function |-Diagnostic endoscopies with no|Invasive diagnostic tests |
|medical decision making| |-UA |-Barium enema |risk factors |-Cardiac electrophysiological|
|level, so this area is | |-Ultrasound |-Arterial puncture |-Deep needle or incisional |tests |
|not usually the deal | |-Venipuncture |-Skin biopsies |biopsy |-Diagnostic endoscopies w/ |
|breaker as most SBHC | |-KOH. | |-Obtained fluid from body |identified risk factors |
|do not typically do | | | |-Cardiovascular imaging w/ |-Discography |
|level 3, 4 or 5 | | | |contrast | |
|Diagnostics) | | | | | |
|Treatment of Management| |-Rest |-OTCs |-Minor surgery with risk |-Elective surgery with |
|Options | |-Gargles |-Minor surgery w/ no |factors |identified risk factors |
| | |-Elastic bandages |identified risk factors |-Elective major surgery - no |-Emergency major surgery |
| | |-Dressings |-PT |risk factors |-Parenteral controlled |
| | | |-OT |-Prescription drug management |substances |
| | | |-IVs without additives |-IV fluids with additives |-Drug treatment requiring |
| | | | |-Closed fracture or dislocation|intense monitoring |
| | | | |treatment w/o manipulation |-Decisions not to resuscitate|
| | | | |-Therapeutic nuclear medicine |or de-escalate care because |
| | | | | |of poor prognosis |
-----------------------
* For a new patient 99201, use the requirements for a new patient 99202
* For a new patient 99201, use the requirements for a new patient 99202
* For a new patient 99201, use the requirements for a new patient 99202
* For a new patient 99201, use the requirements for a new patient 99202
-----------------------
10
NO
NO
NO
99213
625.3
DYSMEN
Documented
(
Billed
(
4
√
NO
NO
NO
99204
493.90
asthma
Documented
(
Billed
(
10
50
50
3
2
2
NO
NO
NO
521
caries
99202
√
Billed
(
Documented
(
3
3
3
3
4
3
43
4ࠀࠁࠉࠦࠧࡀ3
√
2
YES
NO
NO
NO
99382
V20.2
√
2
................
................
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