E/m Audit Score Sheet
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1E/M AUDIT SCORE SHEET
("97" guidelines)
Patient: __________________________________
DOS:____________
New/Established:
N
E
Coder: ___________________________________
Physician: ________________________________
Coder E/M Code: __________________________
Chief Complaint: __________________________
Auditor E/M Code: _________________________
HISTORY
HPI
ROS
How to Score PFSH
location
Const
New Patient:
Pertinent = 2 History Areas
Quality
Eyes
Complete = 3 History Areas
Severity
ENMT
Established Patient:
Pertinent = 1 History Area
Duration
Cardio
Complete = 2 History Areas
Timing
Resp
Context
GI
OVERALL LEVEL OF HISTORY
Mod Fact
GU
How to Score HISTORY
Assoc S/S
Musc
Below, circle the column that best fits the score for each
TOTAL
Skin/Breast
history element. The circle farthest to the LEFT will
Neuro
determine the level of history.
PFSH
Psych
Past Med Hx
Endo
LEVEL >
PF
EPF
D
C
Family Hx
Hem/Lymph
HPI
------>
Brief 1-3
------>
Ext 4+
Social Hx
Allergy/Immun
ROS
None
Pert 1
Ext 2-9
Comp 10+
TOTAL
PFSH
------>
None
Pert 1/2
Comp 2/3
PHYSICAL EXAM
Refer to APPENDIX A for scoring: Titled - General Multi-System Exam ("97" Documentation Guidelines)
1-5 Elements Identified by Bullet
PROBLEM FOCUSED EXAM
>6 Elements Identified by Bullet
EXPANDED PROBLEM FOCUSED EXAM
>2 Elements Identified by Bullet from 6 Areas/Systems
OR
DETAILED EXAM
>12 Elements Identified by Bullet from >2 Areas/Systems
Perform All Elements Identified by Bullet from >9 Area/Systems
AND
COMPREHENSIVE EXAM
Document >2 Elements Identified by Bullet from 9 Area/Systems
MEDICAL DECISION MAKING (MDM)
How to Score A - Multiply the number by the points for the results (Maximun Score = 4)
A: # of DIAGNOSIS or TREATMENT OPTIONS
Categories for Problems/Major New Systems
Number times >
Points =
Results
Self-limited or minor (stable, improved or worsening)
1
Established problem (stable, improved)
1
Established problem (worsening)
2
New problem (no additional workup planned)
3
New problem (additional workup planned)
4
TOTAL
How to Score B - Each category, cirle the number in the points column. Total the points.
B: AMOUNT and/or COMPLEXITY of DATA to be REVIEWED
Categories of Data to be Reviewed
Points
Review and/or order clinical lab test
1
Review and/or order of test in the radiology section of CPT (nuclear medicine and all imaging
except; echocardiography and cardiac cath)
1
Review and/or order of test in the medicine section of CPT (examples; EEG, echocardiography,
cardiac cath, non-invasive vascular studies, pulmonary function studies, physical testing, endoscopy
1
Discussion of test results with performing physician
1
Decision to obtain old records and /or obtain history from someone other than patient
1
Review and summarization of old records and/or obtaining history from someone other than
patient and/or discussion of case with another health care provider
2
Independent visualization of image, tracing or specimen itself (not simply review of report)
2
TOTAL
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