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MCW E&M Audit Tool

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MCW EVALUATION & MANAGEMENT (E/M) AUDIT TOOL

Applicable for: Office/Outpatient, Inpatient, Observation, Consultations, and ED.
Guideline Basis: 2021 & 2023 AMA CPT Guidelines.

Patient Name/MRN:  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DOS:  _ _ _ _ _ _ _ _ _ _ _ _ _ _
Provider:  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Auditor:  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Payer:  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Medicare/Commercial rules may vary for Prolonged Services)

SECTION 1: ENCOUNTER TYPE & CODE SET

Select the category to determine the Base Codes.

Office New (99202-99205)
Office Est. (99212-99215)
Initial Inpatient/Observation (99221-99223)
Subsequent Inpatient/Observation (99231-99233)
Inpatient/Observation Discharge (99238-99239)
Consultations (Inpatient) (99252-99255)
Emergency Dept (99281-99285) (Note: Time cannot be used for ED)

SECTION 2: MEDICAL DECISION MAKING (MDM)

To qualify for a level, 2 of the 3 elements (Problems, Data, Risk) must be met.

ELEMENT 1: Complexity of Problems Addressed

Problem must be evaluated or treated at the encounter. Referral without evaluation counts.

  • MINIMAL (Level 2 )

    • 1 self-limited or minor problem

  • LOW (Level 3 )

  • 2+ self-limited/minor problems
  • 1 stable chronic illness
  • 1 acute, uncomplicated illness/injury
  • 1 stable, acute illness (Inpatient only)
  • MODERATE (Level 4 )
  • 1+ chronic illness w/ exacerbation, progression, or side effects
  • 2+ stable chronic illnesses
  • 1 undiagnosed new problem w/ uncertain prognosis
  • 1 acute illness w/ systemic symptoms
  • 1 acute complicated injury

  • HIGH (Level 5 )

    • 1+ chronic illness w/ severe exacerbation, progression, or side effects
    • 1 acute/chronic illness posing threat to life or bodily function

Element 1 Result:  [ ] Min [ ] Low [ ] Mod [ ] High

ELEMENT 2: Amount/Complexity of Data

Tests ordered/reviewed are distinct unique CPT codes. Panel = 1 test.

  • MINIMAL/NONE (Level 2 )

  • LIMITED (Level 3 ) - (Must meet 1 category)

  • Cat 1: Any combo of 2: Review external notes; Review unique test result; Order unique test.
  • Cat 2: Assessment requiring independent historian.

  • MODERATE (Level 4 ) - (Must meet 1 category)

    • Cat 1: Any combo of 3: Review external notes; Review unique test result; Order unique test; Independent historian.
    • Cat 2: Independent interpretation of test (not separately reported).
    • Cat 3: Discussion of management/interpretation with external provider.

  • EXTENSIVE (Level 5 ) - (Must meet 2 categories)

    • Cat 1: Any combo of 3 items (Same list as Moderate Cat 1).
    • Cat 2: Independent interpretation of test (not separately reported).
    • Cat 3: Discussion of management/interpretation with external provider.

Element 2 Result:  [ ] Min [ ] Ltd [ ] Mod [ ] High

ELEMENT 3: Risk of Complications/Morbidity

Based on consequences of the problem addressed when appropriately treated.

  • MINIMAL (Level 2 )
  • Rest, gargles, elastic bandages.

  • LOW (Level 3 )

    • OTC drugs, PT/OT, Minor surgery w/o risk factors, IV fluids (no additives).

  • MODERATE (Level 4 )

    • Prescription Drug Management
    • Decision regarding minor surgery w/ risk factors.
    • Decision regarding elective major surgery w/o risk factors.
    • Diagnosis/Tx limited by Social Determinants of Health.

  • HIGH (Level 5 )

    • Drug therapy requiring intensive monitoring for toxicity.

    • Decision regarding elective major surgery w/ risk factors.

    • Emergency major surgery.

    • Decision regarding hospitalization or escalation of hospital care.

    • Decision NOT to resuscitate/de-escalate care due to prognosis.

    • Parenteral controlled substances.

  • Element 3 Result: 
  • Min [ ] Low [ ] Mod [ ] High

SECTION 3: TIME-BASED SELECTION

Skip this section if coding by MDM or if Service is ED (9928x).
Time includes face-to-face and non-face-to-face time on the date of encounter.

Activities Documented:
[ ] Prep/Review [ ] Hx/Exam [ ] Counseling [ ] Orders [ ] Documentation [ ] Care Coord.

Total Time:  _ _ _ _ _ _ _ Minutes

Refer to Grid for Code Selection:

  • Office New: (15-29=L2) (30-44=L3) (45-59=L4) (60-74=L5)
  • Office Est: (10-19=L2) (20-29=L3) (30-39=L4) (40-54=L5)
  • Initial Inpatient: (40m=L1) (55m=L2) (75m=L3)
  • Subsequent Inpatient: (25m=L1) (35m=L2) (50m=L3)
  • Consults: (35m=L2) (45m=L3) (60m=L4) (80m=L5)
  • Discharge: (≤30m = 99238 ) ( >30m = 99239 )

SECTION 4: FINAL DETERMINATION

MDM Level Calculation (Drop lowest of the 3 elements):

MDM Result:  _ _ _ _ _ _ _ _ _

Time Based Result:  _ _ _ _ _ _ _ _ _ (N/A if ED)

FINAL CODE SELECTED:  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

  • Correctly Coded
  • Under Coded (Support was present for higher level)
  • Over Coded (Documentation does not support level)

Auditor Notes:

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