Last Modified: 7/31/2014 office visits & consults audit Tool



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Last Modified: 7/31/2014

OFFICE VISITS & CONSULTS - Audit Tool




























Patient Name




MRN




Billed




Audited




Auditor

New Patient Office Visit = 9920x Established Patient Office Visit = 9921x Office Consult = 9924x



HISTORY

HPI

ROS

☐ ☐ Location (site on body)

Quality (characteristic: throbbing, sharp; how the problem feels, looks, behaves: acute, chronic, stable, worsening, waxing/waning)

Severity (1/10, intensity)

Duration (how long for problem/episode)

Timing (when it occurs: throughout the day, morning, at night continuously, etc)

Context (under what circumstances does the patient experience the symptom/problem)

Modifying Factors (what makes it better or worse)

Assoc. Signs/Symptoms (what else is happening when it occurs)



Status of Chronic Conditions 1-2 3

Constitutional (Fevers, chills, weight change, fatigue, general health-feeling okay, sweating, appetite)

Eyes (Wears glasses, blurry vision, eye problems)

Ear, Nose, Mouth, Throat (Hearing loss, ringing in ears, earaches, drainage, sinus problems, nose bleeds, bad breath, sores or bleeding in mouth, voice change, snoring)

Cardiovascular (Chest pain, chest tightness, swelling of feet or hands, palpitations, no edema)

Respiratory (Cough, SOB, wheezing, sputum, coughing up blood)

GI (Change in bowel habits, nausea, vomiting, diarrhea, constipation, belly pain, rectal bleeding)

GU (Frequency, pain or burning on urination, change in force when urinating, blood in urine, incontinence, pain with menstruation, change in menstrual habits, testicle pain)

Musculo (Joint pain or stiffness, swelling, muscle pain, back pain, difficulty walking, gait)

Integumentary - Skin/Breast (Rash, itching, change in skin color, varicose veins, breast pain, lump)

Neuro (Headaches, lightheadedness, dizziness, tremors, numbness or tingling, weakness, paralysis)

Psych (Memory loss, confusion, suicidal ideation, depression, anxiety, hallucinations, behavior problems)

Endocrine (Excessive thirst or urination, heat or cold intolerance, dry skin, night sweats)

Hem/lymph (Bleeding or easy bruising, anemia, phlebitis, enlarged glands)

Allergic/Imm (Sneezing, itching eyes, rhinorrhea, nasal obstruction, or recurrent infections)

☐“All others negative”


PFSH

Past Medical (experiences with illnesses, operations, injuries and treatments, updated medication list and allergies)

Family (a review of pertinent family medical events, diseases, and hereditary conditions that may place patient at risk)

Social (age appropriate review of past and current activities – employment, use of drugs/alcohol/tobacco, marital status, level of education, sexual history)
☐ History was unobtainable due to ______.





HPI

☐ 1-3

☐ 1-3

Or status of 1-2 chronic conditions



☐ 4+

☐ 4+

Or status of 3 chronic conditions






ROS

☐ None

☐ 1

☐ 2-9

☐ 10+




PFSH

☐ None

☐ None

☐ 1-2 (new pt/consult)

☐ (1 if Est pt)



☐ 3 (new pt/consult)

☐ (2-3 if Est pt)






HISTORY LEVEL

(choose lowest)

Problem Focused



Expanded Problem Focused



Detailed



Comprehensive






1995 EXAM

Constitutional (vital signs, general appearance, no acute distress) Hem/lymph/Imm (no lymph nodes palpable)

Eyes Ear, Nose, Mouth, Throat (teeth)

Cardiovascular (carotids, edema, pedal pulses, capillary refill) Respiratory (percussion/auscultation)

GI (GI: no tenderness, HSM, normal bowel sounds ) GU

Musculo (clubbing, cyanosis, CVA tenderness) Integumentary - Skin/Breast (rashes, tattoos, piercings)

Neuro Psych (affect – alert & oriented)

OK to use “negative” or “normal” alone but if “abnormal” details must be added.

☐ Head (Including face) Chest (including breast/axillae) Abdomen Left Arm Right Arm

☐ Neck Back Genitalia/groin/buttocks Left Leg Right Leg


# of organ systems/body areas

Limited to affected organ system/body area

2-4

5-7

8+

Organ Systems



EXAM LEVEL

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Medical Decision Making Elements




A) # OF DIAGNOSIS/MANAGEMENT OPTIONS (Problems to Examining Provider)

Points

B) AMOUNT AND/OR COMPLEXITY OF DATA TO REVIEW (Data Reviewed by Examining Provider)

Points

Self-limited or minor (stable, improved, worsening) = 1 pt each, Max = 2




Review and/or order LAB tests

1

Est. problem (to examiner) stable, improved

= 1 pt each






Review and/or order RADIOLOGY tests

1

Est. problem (to examiner) worsening = 2 pt ea




Review and/or order MEDICINE tests

1

New problem (to examiner) no additional workup = 3 pt each




Discussion of test results with performing physician

1

New problem (to examiner) additional workup

= 4 pt each






Decision to obtain old records and/or obtain history from someone other than patient

1

A) Total




Review & summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider

2







Independent visualization of image, specimen or tracing (NOT simply review of report)

2







B) Total







C) RISK OF COMPLICATIONS, MORBIDITY and/or MORTALITY




RISK

Presenting problems

Dx procedures ordered

Management options




Min

☐ 1 minor or self-limited (cold, insect bite, tinea corporis)

☐ Venipuncture, CXR, EKG, EEG, UA, ultrasound/echo, KOH prep

☐ Rest, gargle, elastic bandages, superficial dressings




Low

☐ 2 or more minor;

1 stable chronic problem; Acute uncomp illness/injury (cystitis, sprain, allergic rhinitis)



☐ Physiologic tests NOT under stress; Non CV imaging w/ contrast (barium enema); Superficial needle biopsy; skin biopsies

☐ OTC drugs; PT, OT; IV fluids without additives; Minor surgery NO risk factors




Mod

☐ Mild exac of chronic prob; 2 stable chronic prob; Acute illness + system Sx (pyelonephritis, colitis); Acute complicated injury (head injury brief loss of consciousness); Undiagnosed new problem w/ uncertain prognosis

☐ Physiologic tests under stress; Dx endoscopies NO risk factors; Deep needle or incisional bx; CV imaging + contrast; Obtain fluid from body cavity

☐ Minor surgery + risk factors; Elective major surgery; Prescription drug therapy/management; Therapeutic nuclear medicine; IV fluids + additives




High

☐ Severe exac of chronic prob or side effect of tx; Acute or chronic illness posing threat to life/limb; Abrupt change neuro status (seizure, TIA, weakness/sensory loss)

☐ CV imaging + contrast, risk factors; Card electrophysiological studies; DX endoscopies + risk factors; Discography

☐ Elective major surg + risk factors; Emergency major surg; Parenteral controlled sub; Rx requiring intense monitoring; DNR or de-escalation of care







A

1 or less - Minimal

2 – Limited

3 – Multiple

4 – Extensive







B

1 or less - Minimal

2 – Limited

3 – Multiple

4 – Extensive







C

Minimal

Low

Moderate

High







MDM Level

(choose column w/ 2-3 checks or center column)

SF



Low



Moderate



High






New Office Visit or Consult (need 3 of 3)




Established Office Visit (need 2 of 3)

HISTORY

☐ PF

☐ EPF

☐ D

☐ C

☐ C




HISTORY

Nurse Visit



☐ PF

☐ EPF

☐ D

☐ C

EXAM

☐ PF

☐ EPF

☐ D

☐ C

☐ C




EXAM

☐ PF

☐ EPF

☐ D

☐ C

MDM

☐ SF

☐ SF

☐ L

☐ M

☐ H




MDM

☐ SF

☐ L

☐ M

☐ H

LEVEL

1

2

3

4

5




LEVEL

1

2

3

4

5

Time Based Billing (in minutes)




Time Based Billing (in minutes)

New Office

☐ 10

☐ 20

☐ 30

☐ 45

☐ 60




Est Office

☐ 5

☐ 10

☐ 15

☐ 25

☐ 40

Off. Consult

☐ 15

☐ 30

☐ 40

☐ 60

☐ 80




TIME: If ALL responses regarding time are "Yes," billing may be based on time.

*If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, or risk education.



  • Does documentation reveal total face-to-face time? Yes No

  • Does documentation discuss the content of counseling or coordination of care? Yes No

  • Does documentation reveal that more than 50% of the time was spent on counseling or coordination of care? Yes No


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