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Evaluation and Management (E&M) Audit FormColorado Workers’ Compensation Exhibit #7Audit Form A is used to determine level of service based on Time.If time is used to establish the level of visit and total amount of time falls in between two (2) levels, then the provider’s time shall be more than half way to reaching the higher level.If greater than 50% of a physician’s time at an E&M visit is spent either face-to-face with the patient counseling and/or coordination of care, with or without an interpreter, and there is detailed patient specific documentation of the counseling and/or coordination of care, then time can determine the level of service.Documentation must be patient specific and pertain directly to the current visit. Information copied directly from prior records without change is not considered current nor counted.If timing of counseling or coordination of care is done within the 24 hours prior to, or within seven business days after the patient encounter, then a telephonic CPT? code may be appropriate. Audit Form B is used to determine level of service based on Key Components.If the 3 key components are being used, the history, examination, and medical decision making will determine level of the E&M service.Under the examination component, each bullet is counted only when it is pertinent and related to the workers’ compensation injury and the decision making process. Documentation must be patient specific and pertain directly to the current visit. Information copied directly from prior records without change is not considered current nor counted.Functional gains must be documented and patient specific.Evaluation and Management (E&M) Audit Form Colorado Workers’ Compensation Exhibit #7Injured Worker’s Name:_______________________________ FORMCHECKBOX New FORMCHECKBOX Established Date of Injury ____/____/____ Is this a consultation? FORMCHECKBOX Yes FORMCHECKBOX NoProvider’s Name: ________________________________________Reviewing/Paying Insurer Name: ____________________________________________Place of Service: FORMCHECKBOX Office FORMCHECKBOX Hospital FORMCHECKBOX Freestanding facility FORMCHECKBOX ERD FORMCHECKBOX Other_______________ Date of Service ____/____/____ Chief Complaint (required): _______________________________________________________________Medical necessity of the visit must be identifiable somewhere within the written report. (Required)Consultation Criteria Required in Rule 18 must be met in order to bill for any of the inpatient or outpatient consultation codes (CPT? 99241-99255). All 3 criteria must be documented in the billing providers report: The report states who requested the consultation in the report. FORMCHECKBOX Met FORMCHECKBOX Not MetThe report contains one of the following reasons for a consultation: FORMCHECKBOX Met FORMCHECKBOX Not MetA specified diagnosis confirmation Symptom evaluation/diagnosis by a specialistEvaluation for acceptance of patients ongoing care for a specified condition or problem 3. The consultant’s report was submitted to the requesting provider as a: FORMCHECKBOX Met FORMCHECKBOX Not Meta. Carbon Copy (CC); or Addressed directly to the requesting providerMedical Documentation Guidelines Used for this Audit:Exhibit #7 to Rule 18, in effect on dates of service using: FORMCHECKBOX TIME: Counseling/Coordination of Care was > 50% of visit (Use Form A) FORMCHECKBOX KEY COMPONENTS (Use Form B) FORMCHECKBOX Medicare’s 1997 Documentation Guidelines (Do not use this Audit Form)Audit Form A: TIMETiming of Counseling or Coordination of Care in Relation to VisitDid the counseling or coordination of care occur more than 24 hours prior to the actual patient encounter? Yes FORMCHECKBOX or No FORMCHECKBOX Did the counseling or coordination of care occur more than seven (7) business days after the actual patient encounter?Yes FORMCHECKBOX or No FORMCHECKBOX If both answers are no, continue to section A or B. If yes, level of service cannot be based on time.Counseling (Questions a-c & e must be answered yes for time to be used)Is total time of the visit documented? Yes FORMCHECKBOX or No FORMCHECKBOX Was > 50% of the time spent with the patient counseling? Yes FORMCHECKBOX or No FORMCHECKBOX Did the documentation support the patient was an active participant during the counseling? Yes FORMCHECKBOX or No FORMCHECKBOX Check which of the following face-to-face physician counseling topics were done with the patient and/or their family at that visit: FORMCHECKBOX Injury/disease education that includes discussion of diagnostic tests results and treatment plan. FORMCHECKBOX Return to work, temporary and/or permanent restrictions FORMCHECKBOX Review of other physicians’ notes (i.e., IME consultation) FORMCHECKBOX Self-management of symptoms while at home and/or work FORMCHECKBOX Correct posture/mechanics to perform work functions FORMCHECKBOX Exercises for muscle strengthening and stretching FORMCHECKBOX Appropriate tool/equipment use to prevent re-injury and/or worsening of injury/condition FORMCHECKBOX Patient/injured worker expectations and specific goals FORMCHECKBOX Family and other interpersonal relationships and how they relate to psychological/social issues FORMCHECKBOX Discussion of pharmaceutical management (includes drug dosage, specific drug side effects and potential of addiction /problems) FORMCHECKBOX Assessment of vocational plans (e.g., restrictions as they relate to current and future employment job requirements) FORMCHECKBOX Discussion of the workers’ compensation process (i.e. IMEs, MMI, role of case manager) Is there specific documentation of the counseling (identifies the issues, decisions made, etc)? Yes FORMCHECKBOX or No FORMCHECKBOX Additional items/topics discussed with the patient during counseling: ________________________________________________________________________________Coordination of Care (Both answers must be yes and the person(s) and services/treatments identified)Is total time of the visit documented? Yes FORMCHECKBOX or No FORMCHECKBOX Was > 50% of the time spent coordination of care documented? Yes FORMCHECKBOX or No FORMCHECKBOX Who was care coordinated with: ______________________________________ FORMCHECKBOX Employer FORMCHECKBOX Physician in another office FORMCHECKBOX PT/OT FORMCHECKBOX Nurse Case Manager FORMCHECKBOX Insurer FORMCHECKBOX Other ______________________________________What specific services/treatments were coordinated? (check all that apply) FORMCHECKBOX RTW FORMCHECKBOX Treatment FORMCHECKBOX Diagnostic Testing FORMCHECKBOX Other______________________________________ Audit Form A: TIME cont.Final Result: (Circle the E&M Level as determined by the Documentation Guideline Used) New Patient/Office Consultations Established Patient Office VisitLevel of ServiceAvg. time (minutes) as listed for the specific CPT? code99201 / 992411099202 / 992422099203 / 992433099204 / 992444599205 / 9924560Level of ServiceAvg. time (minutes) as listed for the specific CPT? code9921159921210992131599214259921540Billed E&M CPT? code: ______________Audited E&M Level code: ____________42767256921500If billed level of service has been met based on timeAudit Form B: KEY COMPONENTS - HistoryHistory of Present Illness (HPI)Review of Systems (ROS) FORMCHECKBOX Location FORMCHECKBOX Constitutional symptoms FORMCHECKBOX Quality FORMCHECKBOX Eyes FORMCHECKBOX Severity FORMCHECKBOX Ears, Nose, Mouth, Throat FORMCHECKBOX Duration FORMCHECKBOX Cardiovascular FORMCHECKBOX Timing FORMCHECKBOX Respiratory FORMCHECKBOX Context FORMCHECKBOX Gastrointestinal FORMCHECKBOX Modifying factors FORMCHECKBOX Genitourinary FORMCHECKBOX Associated signs FORMCHECKBOX Musculoskeletal FORMCHECKBOX Integumentary (skin and/or breast)Total # of HPIs documented: ______ FORMCHECKBOX Neurological FORMCHECKBOX Psychiatric FORMCHECKBOX Endocrine FORMCHECKBOX Hematologic/Lymphatic FORMCHECKBOX Allergic/ImmunologicPast Medical, Family, Social, Occupational History (PMFSOH)Check Applicable 1-4 types of histories documented FORMCHECKBOX Patient current and past medical FORMCHECKBOX Social ____Current medications ____Living arrangements ____Prior illnesses ____Marital Status ____Operations and hospitalization ____Sexual history ____Allergies ____Use of drugs, alcohol, or tobacco ____Injuries ____Current and/or past physical activities ____Current and/or past hobbies FORMCHECKBOX Family ____Patient’s emotional support system ____Parents, siblings, etc. ____Identified issues for RTW or Tx Plan ____Hereditary disease(s) ____Diseases related FORMCHECKBOX Occupational ____Currently working or not ____Review of past job history ____Past occupational history ____EducationTotal # of types of PMFSOHs documented: _______Audit Form B: KEY COMPONENTS - History cont.The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be documented and met. ElementsProblem Focused Expanded Problem Focused Detailed Comprehensive HPI FORMCHECKBOX Brief 1-3 elements FORMCHECKBOX Brief 1-3 elements FORMCHECKBOX Extended 4+ elements Initial visits: FORMCHECKBOX Injury causation statement and/or an objective functional goal treatment plan. Follow-up visits: FORMCHECKBOX Detailed description of patient specific progress since the last visit with the current treatment plan, including objective functional gains/losses, ADLs, RTW, etc. FORMCHECKBOX Extended 4+ elements Initial visits: FORMCHECKBOX Injury causation statement and/or an objective functional goal treatment plan.Follow-up visits: FORMCHECKBOX Detailed description of patient specific progress since the last visit with the current treatment plan, including objective functional gains/losses, ADLs, RTW, etc.ROS FORMCHECKBOX Present - should be qualitative versus quantitative, documenting what is pertinent to that patient for the date of service.PMFSOH FORMCHECKBOX None FORMCHECKBOX Pertinent 1 of 4 types of histories FORMCHECKBOX 3 or more of the 4 types of historiesHistory Result: FORMCHECKBOX Problem Focused (PF) FORMCHECKBOX Expanded Problem Focused (EPF) FORMCHECKBOX Detailed (D) FORMCHECKBOX Comprehensive (C) Audit Form B: KEY COMPONENTS - Physical Exam(Parenthesis contain examples and are not all inclusive)Constitutional Measurements: three or more = 1 bullet FORMCHECKBOX Sitting or standing B/P FORMCHECKBOX Supine B/P FORMCHECKBOX Pulse rate and regularity FORMCHECKBOX Respirations FORMCHECKBOX Temperature FORMCHECKBOX Height FORMCHECKBOX Weight or BMI 3 or more Constitutional Measurements FORMCHECKBOX 1 bulletMusculoskeletal Separate Body Areas: any three (3) assessments of a body area = 1 bulletInspection, percussion, and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusionsAssessment of range of motion with notation of any pain (straight leg raising) crepitation or contracturesAssessment of stability with notation of any dislocation (luxation), subluxation or laxityAssessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)3 checks in a body area = 1 bulletHead and/or Neck: A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletSpine, Ribs and/or Pelvis A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletUpper Right ExtremityA FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletUpper Left ExtremityA FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletLower Right ExtremityA FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletLower Left ExtremityA FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX FORMCHECKBOX 1 bulletInspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechia, ischemia, infections, nodes) FORMCHECKBOX 1 bulletGeneral Appearance if not addressed under neuro or psych (development, nutrition, body habitus, deformities, attention to grooming). FORMCHECKBOX 1 bulletNeck: (both) Neck exam (masses, overall appearance, symmetry, tracheal position) Thyroid exam (enlargement, tenderness, mass) FORMCHECKBOX 1 bulletEyes: (all 3 examinations for both eyes )Inspection of conjunctivae and lids; and Examination of pupils and irises (reaction of light and accommodation, size and symmetry); and Ophthalmoscopic examination of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudates, hemorrhages) FORMCHECKBOX 1 bulletSkin: Inspection of pertinent body parts and/or palpation of skin and subcutaneous tissue (scars, rashes, lesions, café ’au lait spots, ecchymosis, ulcers) FORMCHECKBOX 1 bullet Total # of bullets from Physical Exam page 1 of 3: _______ Audit Form B: KEY COMPONENTS - Physical Exam cont.Examination of Gait and Station FORMCHECKBOX 1 bulletNeurological: one bullet for each neurological examination/assessment per extremity.Test Coordination (finger to nose, heel/knee/shin, rapid alternative movements) Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes Examination of sensation (touch, pin, vibration, proprioception) Upper Right ExtremityA FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Upper Left Extremity A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Lower Right Extremity A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Lower Left Extremity A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Total # of bullets: _______All 12 cranial nerves assessment with notations of any deficits FORMCHECKBOX 1 bulletCardiovascular: Palpation of heart (location, size, thrills) FORMCHECKBOX 1 bullet Auscultation of heart with notation of abnormal sounds and murmurs FORMCHECKBOX 1 bulletCarotid arteries (pulse amplitude, bruits) FORMCHECKBOX 1 bulletAbdominal aorta (size, bruits) FORMCHECKBOX 1 bulletFemoral arteries (pulse amplitude, bruits) FORMCHECKBOX 1 bulletPedal pulses (pulse amplitude) FORMCHECKBOX 1 bulletExtremities for edema and/or varicosities FORMCHECKBOX 1 bulletRespiratory: Assessment of respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement) FORMCHECKBOX 1 bulletPercussion of chest (dullness, flatness, hyperresonance) FORMCHECKBOX 1 bulletPalpation of chest (tactile fremitus) FORMCHECKBOX 1 bulletAuscultation of lungs (breath sounds, adventitious sounds, rubs) FORMCHECKBOX 1 bulletGastrointestinal:Examination of abdomen, including liver and spleen, with notation of presence of masses or tenderness FORMCHECKBOX 1 bulletExamination of presence or absence of hernia FORMCHECKBOX 1 bulletExamination of anus, perineum and rectum, including sphincter tone, present of hemorrhoids, rectal masses and/or obtain stool sample of occult blood test FORMCHECKBOX 1 bulletLymphatic palpation of lymph nodes – two (2) or more areas: FORMCHECKBOX 1 bulletNeck, Axillae, Groin, Other:___________________________Chest: Both examinations/assessments of both breasts FORMCHECKBOX 1 bulletInspection of breasts (symmetry, nipple discharge); andPalpation of breasts and axillae (masses or lumps, tenderness) Total # of bullets from Physical Exam page 2 of 3: _______ Audit Form B: KEY COMPONENTS - Physical Exam cont.Psychiatric:Assessment of mood and affect (depression, anxiety, agitation) if not counted under the Neurological system FORMCHECKBOX 1 bulletMental status examination which includes: FORMCHECKBOX 1 bulletAttention span and concentration; andLanguage (naming objects, repeating phrases, spontaneous speech) orientation to time, place and person; andRecent and remote memory; andFund of knowledge (awareness of current events, past history, vocabulary)Ears and Nose, Mouth and Throat:All of the following examination/assessment: FORMCHECKBOX 1 bulletExternal inspection of ears and nose (overall appearance, scars, lesions, rashes)Otoscopic examination of external auditory canals and tympanic membranesAssessment of hearing with tuning fork and clinical speech reception thresholds (whispered voice, finger rub, tuning fork)All of the following examinations/assessments: FORMCHECKBOX 1 bulletInspection of nasal mucosa, septum and turbinatesInspection of lips, teeth and gumsExamination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx (asymmetry, lesions, hydration of mucosal surfaces)Genitourinary:Male Examination: Scrotal contents (hydrocele, spermatocele, tenderness of cord) FORMCHECKBOX 1 bulletEpididymides (size, symmetry, masses) FORMCHECKBOX 1 bulletTestes (size symmetry, masses) FORMCHECKBOX 1 bulletUrethral meatus (size location, lesions, discharge) FORMCHECKBOX 1 bulletExamination of the penis (lesions, presence of absence of foreskin, foreskin FORMCHECKBOX 1 bullet retractability, plaque, masses, scarring, deformities)Digital rectal examination of prostate gland (size, symmetry, nodularity, FORMCHECKBOX 1 bullet tenderness)Inspection of anus and perineum FORMCHECKBOX 1 bulletFemale Examination (with or without specimen collection):External genitalia (general appearance, hair distribution, lesions) and vagina FORMCHECKBOX 1 bullet (general appearance, discharge, lesions, pelvic support, cystocele rectocele)Examination of urethra (masses, tenderness, scarring) FORMCHECKBOX 1 bulletExamination of bladder (fullness, masses, tenderness) FORMCHECKBOX 1 bulletCervix (general appearance, lesions, discharge) FORMCHECKBOX 1 bulletUterus (size, contour, position, mobility, tenderness, consistency, descent FORMCHECKBOX 1 bullet or support)Adnexa/parametria (masses, tenderness, organomegaly, nodularity) FORMCHECKBOX 1 bulletTotal # of bullets from Physical Exam page 3 of 3: _______ Audit Form B: KEY COMPONENTS - Physical Exam cont.Each bullet is counted only when is it pertinent and related to the workers’ compensation injuryand the medical decision making process.Total # of bullets added from Physical Exam pages 1-3: ________Level of Examination# of Bullets Required for each LevelProblem Focused (PF) FORMCHECKBOX 1 to 5 elements identified by a bullet as indicated in this guidelineExpanded Problem Focused (EPF) FORMCHECKBOX 6 elements identified by a bullet as indicated in this guidelineDetailed (D) FORMCHECKBOX 7-12 elements identified by a bullet as indicated in this guidelineComprehensive (C) FORMCHECKBOX > 13 elements identified by a bullet as indicated in this guidelinePhysical Exam Result: Audit Form B: KEY COMPONENTS – Medical Decision Making Number of Diagnosis & Management Options (multiply occurrence by value)Category of Problem(s)OccurrenceValuePointsSelf-limited or minor problem(max = 2)X1=Established problem, stable or improved X1=Established problem, minor worseningX2=Established patient with worsening of condition and no additional workup planned(max = 1)X3=Established patient with less than anticipated improvement,Worsening of condition and additional workup plannedX4=New problem with no additional workup planned; or (max = 1)X3=New problem, with additional workup planned X4=Total2. Amount and/or Complexity of Data Reviewed PointsLab(s) ordered and/or reports reviewed 1X-ray(s) ordered and/or reports reviewed 1Discussion of test results with performing physician 1Decision to obtain old records and/or obtain history from someone other than the patient 1Medicine section (CPT? 90701-99199) ordered and/or physical therapy reports reviewed and commented on progress (state whether the patient is progressing and how they are functionally progressing or not and document any planned changes to the plan of care) 2 Review and summary of old records and/or discussion with other health provider 2Independent visualization of images, tracing or specimen 2TotalAudit Form B: KEY COMPONENTS – Medical Decision Making Cont.3. Table of Risk (the highest one in any one category determines the overall risk for this portion) (circle what is determining the level)Level of RiskPresenting Problem(s)Diagnostic Procedure(s) Ordered or AddressedManagement Option(s) SelectedMinimal FORMCHECKBOX One self-limited or minor problem, e.g., cold, insect bite, tinea corporis, minor non-sutured lacerationLab tests requiring venipuncture, Chest x-raysEKG/EEG, Urinalysis, Ultrasound,KOH prepRest, Gargles, Elastic bandagesSuperficial dressingsLow FORMCHECKBOX Two or more self-limited orminor problemsOne stable chronic illness, e.g., well-controlled HTN, NIDDM, cataract, BPHAcute, uncomplicated illness or injury, e.g., allergic rhinitis or simple sprain, cystitis, acutelaceration repairPhysiologic tests nor under stress, e.g., PFTs, Non-cardiovascular imaging studies w/contrast, e.g., barium enemaSuperficial needle biopsiesLab tests requiring arterial punctureSkin biopsiesOver-the-counter drugsMinor surgery w/no identified risk factorsPT/OTIV fluids w/o additivesSimple or layered closureVaccine injectionModerate FORMCHECKBOX One of more chronic illnesses with mild exacerbation, progression or side effects of treatmentTwo or more stable chronic illnessesUndiagnosed new problem with uncertain prognosis, e.g., new extremity neurologic complaints. Acute illness with systemic symptoms, e.g., pyelonephritis, colitis. Acute complicated injury, e.g., head injury with brief loss of consciousnessPhysiologic tests under stress, e.g. cardiac stress test Discography, Diagnostic injections Deep needle or incisional biopsiesCardiovascular imaging studies with contrast and no identified risk factors e.g. arteriogram, cardiac catheterizationObtain fluid from body cavity, e.g., , thoracentesis, lumbar punctureMinor surgery with identified risk factorsElective major surgery (open, percutaneous, or endoscopic) with no identified risk factorsPrescription drug management Therapeutic nuclear medicine IV fluids with additivesClosed treatment of fracture or dislocation w/o manipulationDisability counseling and/or workrestrictionsInability to return work & requiring detailed functional improvement planHigh FORMCHECKBOX One or more chronic illness with severe exacerbation, progressionor side effects of treatmentAcute or chronic illness or injury that poses a threat to lifeor bodily function, e.g., multiple trauma, acute MI, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others Abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory lossCardiovascular imaging studies with contrast with identified risk factorsCardiac electrophysiological testsDiagnostic endoscopies with identified risk factorsElective major surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug therapy requiring intensive monitoring for for toxicityDecision not to resuscitate or to de-escalatecare because of poor prognosis. Potential for permanent work restrictions or total disability which would significantly restrict employment opportunities Management of addiction behavior or other significant psychiatric condition. Treatment plan for patients with symptoms causing severe functional deficits withoutsupporting physiological findings or verified related medical diagnosis.Audit Form B: KEY COMPONENTS – Medical Decision Making Cont.Overall Medical Decision Making is determined by 2 of the 3 tables that are at the same or higher level.Level of RiskTotal from Table 1Total from Table 2 Result from Table of RiskStraight Forward (SF)0-10-1MinimalLow (L)22LowModerate (M)33ModerateHigh (H)44HighMedical Decision Making Result: FORMCHECKBOX SF FORMCHECKBOX L FORMCHECKBOX M FORMCHECKBOX HFinal Result: New Patient Office Visit/ Office Consultations – requires all three key components at the same level or higher.New Patient ExamHistoryPFEPFDCCPhysical ExamPFEPFDCCMDMSFSFLMHLevel99201992419920299242992039924399204992449920599245Established Patient Office Visit/ Office Consultations – requires at least two of the three key components at the same level or higher, and one of the two must be MDM.Established Patient ExamHistoryMinimal problem that may not require physician’s presencePFEPFDCPhysical ExamPFEPFDCMDMSFLMHLevel9921199212992139921499215Billed E&M CPT? code: ______________Audited E&M Level code: ____________ ................
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