Hope this helps you. Good luck
ER Audit Sheet
Patient Name: HISTORY Dr.
HPI Location Severity Timing Quality
Context Duration Associated Signs & Sx Modifying Factors
99281-99283 (1-3 elements) 99284-99285 (4 or more elements)
ROS Constitutional Eyes ENT and Mouth Cardiac
Gastrointestinal Musculoskeletal Endocrine Neurological
Integumentary Psychiatric Genitourinary Allergic/Immunologic
Respiratory Hematologic/Lymphatic All others negative
99281 (none) 99284 (2-9 elements)
99282-99283 (1 element) 99285 (10 or more elements)
PFSH Past Family Social
99281-99283 (none) 99284 (1 element) 99285 (2 elements)
EXAM
Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory
Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic
Psychiatric Hematologic/Lymphatic/Immunologic
Body Areas:
99281 Requires at least 1 organ system/body area Head & Face Neck
99282-99283 Requires 2-4 organ systems/body areas Chest/Breast/Axillae Abdomen
99284 Requires 5-7 organ systems/body areas Genitalia/Groin/Buttocks Back
99285 Requires 8 or more organ systems Each Extremity: RUE LUE RLE LLE
Medical Decision Making
Number of Diagnoses/Management Options
Self-limited or minor (Stable, improved or worsened) è Maximum 2 points in this category. 1 point
Established problem (to examining MD); stable or improved 1 point
Established problem (to examine MD); worsening 2 points
New problem (to examining MD); no additional work-up planned è Maximum 1 point in this category. 3 points
New problem (to examining MD); additional work-up (e.g. admit/transfer) 4 points
Amount and/or Complexity of Data Reviewed
Lab ordered and/or reviewed (regardless of # ordered) 1 point
X-ray ordered and/or reviewed (regardless of # ordered) 1 point
Medicine section (90701-99199) ordered and/or reviewed 1 point
Discussion of test results with performing physician 1 point
Decision to obtain old record and/or obtain hx from someone other than patient 1 point
Review and summary of old records and/or obtaining hx from someone other than patient and/or discussion with other health provider
2 points
Independent visualization of image, tracing, or specimen (not simply review of report) 2 points
Risk of complications and/or Morbidity or Mortality
Presenting Problem Diagnostic Tests Management Options Risk
1 self-limited/minor problem Lab w/venipuncture, CXR, EKG, U/A Rest, Gargle, Ace, superficial dressing Minimal
2 or more self-limited/minor
1 stable chronic illness, acute uncomplicated
Lab w/arterial puncture
Superficial needle biopsies
OTC drugs, IV w/o additives Low
1 chronic illness w/exacerbation, 2 or more stable chronic illnesses, new problem w/ uncertain progress, acute problem LP, thoracentesis, culdocentesis Rx, IV w/ additives
Tx of Fx w/o manipulation
Minor surgery w/identified risk factors
Moderate
1 or more chronic illnesses w/severe exacerbation, life threatening illness/injury, suicide/homicidal ideation, neurostatus change Endoscopy with identified risk factors Parenteral controlled drug therapy with monitoring
Emergency Major surgery
High
Final Results of Medical Decision Making
The highest level attained in 2 out of 3 categories will determine your level of E/M code as it relates to medical decision making.
Number of Dx or Tx Options 1 2 3 4
Amount and/or Complexity of data to be reviewed 1 2 3 4
Risk of Complications, Morbidity, Mortality Minimal Low Moderate High
E/M Level=2 out of 3 99281 99282 99283/99284 99285
History* _______ Exam* _______ MDM* _______ = Level of Service*>>> 99281 99282 99283 99284 99285
(*lowest of each category)
☐ Downcoded from Level ______ to Level _______ due to:
