MDM Only Audit Sheet

Appendix 1. Audit Worksheets

Evaluation and Management Services Worksheets Office and Other Outpatient Services Audit Worksheet The following worksheet may be used to collect the necessary data when auditing a medical record for office and other outpatient services (99202-99205 and 99212-99215). Practices can choose to create a custom audit worksheet for each type of E/M service (e.g., office, hospital inpatient or observation care, nursing facility visit, etc.) as in this example, or they can create one audit worksheet for all E/M services.

Appendix 1. Audit Worksheets

Medical Decision Making

Code/Level of MDM (Based on 2 out of 3 Elements of MDM)	Level of MDM (Based on 2 out of 3 Elements of MDM) Number and Complexity of Problems Addressed	Amount and/or Complexity of Data to be Reviewed and Analyzed Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.	Risk of Complications and/or Morbidity or Mortality of Patient Management
99211	N/A	N/A	N/A
Straightforward	Minimal ☐ 1 self-limited or minor problem	☐ Minimal or none	☐ Minimal risk of morbidity from additional diagnostic testing or treatment
Low	Low ☐ 2 or more self-limited or minor problems; or ☐ 1 stable chronic illness; or ☐ 1 acute, uncomplicated illness or injury; or ☐ 1 stable, acute illness; or ☐ 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care	☐ Limited (Must meet the requirements of at least 1 of the 2 categories) ☐ Category 1: Tests and documents • Any combination of 2 from the following:  - Review of prior external note(s) from each unique source*  - Review of the result(s) of each unique test*  - Ordering of each unique test* or ☐ Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)	☐ Low risk of morbidity from additional diagnostic testing or treatment
Moderate	Moderate ☐ 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or ☐ 2 or more stable chronic illnesses; or ☐ 1 undiagnosed new problem with uncertain prognosis; or ☐ 1 acute illness with systemic symptoms; or ☐ 1 acute, complicated injury	☐ Moderate (Must meet the requirements of at least 1 out of 3 categories) ☐ Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following:  - Review of prior external note(s) from each unique source*  - Review of the result(s) of each unique test*  - Ordering of each unique test*  - Assessment requiring an independent historian(s) or ☐ Category 2: Independent interpretation of tests  - Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) or ☐ Category 3: Discussion of management or test interpretation  - Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)	☐ Moderate risk of morbidity from additional diagnostic testing or treatment Examples only:  - Prescription drug management  - Decision regarding minor surgery with identified patient or procedure risk factors  - Decision regarding elective major surgery without identified patient or procedure risk factors  - Diagnosis or treatment significantly limited by social determinants of health
High	High ☐ 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or ☐ 1 acute or chronic illness or injury that poses a threat to life or bodily function	Extensive (Must meet the requirements of at least 2 out of 3 categories) ☐ Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following:  - Review of prior external note(s) from each unique source*;  - Review of the result(s) of each unique test*;  - Ordering of each unique test*;  - Assessment requiring an independent historian(s) or ☐ Category 2: Independent interpretation of tests  - Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) or ☐ Category 3: Discussion of management or test interpretation  - Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)	☐ High risk of morbidity from additional diagnostic testing or treatment Examples only:  - Drug therapy requiring intensive monitoring for toxicity  - Decision regarding elective major surgery with identified patient or procedure risk factors  - Decision regarding emergency major surgery  - Decision regarding hospitalization or escalation of hospital-level care  - Decision not to resuscitate or to de-escalate care because of poor prognosis  - Decision regarding parenteral controlled substance
Audit Worksheets

Office and Other Outpatient Services Audit Worksheet - Time Only Reporting

Record Number		DOS billed
Attending		Signed	Yes ☐	No ☐	DOS Rendered
History		Was a medically appropriate history documented?				Yes ☐	No ☐
Examination		Was a medically appropriate exam documented?				Yes ☐	No ☐

The table below shows the time required for each code.

Code	History & Exam	Medical Decision Making	Time in Minutes
99202	Medically appropriate	Straightforward	≥ 15
99203	Medically appropriate	Low level	≥ 30
99204	Medically appropriate	Moderate level	≥ 45
99205	Medically appropriate	High level	≥ 60
99211*	N/A	N/A	N/A
99212	Medically appropriate	Straightforward	≥ 10
99213	Medically appropriate	Low level	≥ 20
99214	Medically appropriate	Moderate level	≥ 30
99215	Medically appropriate	High level	≥ 40

*Physician presence is not required; presenting problems are minimal

The following activities are included in the provider’s time when performed: ☐ Preparing to see the patient (e.g., review of tests) ☐ Performing a medically appropriate examination and/or evaluation ☐ Care coordination (not reported separately) ☐ Counseling and educating the patient/family/caregiver ☐ Documenting clinical information in the electronic or other health record ☐ Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver ☐ Obtaining and/or reviewing separately obtained history ☐ Ordering medications, tests, or procedures ☐ Referring and communicating with other health care professionals

Was code 99417 reported for prolonged services? Yes ☐ No ☐ The table below shows the time required to report each unit of 99417 in addition to 99205 of 99215.

New Patient	Code
60-74 minutes	99205
75-89 minutes	99205 x1 and 99417 x1
90-104 minutes	99205 x1 and 99417 x2
105 or more minutes	99205 x1 and 99417 x3 or more for each additional 15 minutes
Established Patient	Code
40-54 minutes	99215
55-69 minutes	99215 x1 and 99417 x1
70-84 minutes	99215 x1 and 99417 x2
85 or more minutes	99215 x1 and 99417 x3 or more for each additional 15 minutes

Appendix 1. Audit Worksheets

Medicine Auditing Worksheet

Account/medical record number: ____________ Date of service: ____________

Reviewer: ____________ Date of review: ____________

Type of review: ____________

Immunizations/Vaccines/Toxoids — CPT® Code Assignment

Substance	Code Assignment	Code Documented	Face-to-Face Counseling Documented	E/M Service Documented	E/M Service Billed	Comments

Therapeutic/Prophylactic Injections — CPT Code Assignment

Substance	Code Assignment	Code Documented	Face-to-Face Counseling Documented	E/M Service Documented	E/M Service Billed	HCPCS Level II Code Reported

Number of Units

Billed	Documented	Comments

Other Medical Services — CPT Code Assignment

Procedure	Code Assignment	Code Documented	Modifier Assigned	Modifier Documented	Comments

Place of Service

Indicated on Claim	Documented	Indicated on Claim	Documented

Number of Units

Billable Supplies

Undercoding	Overcoding	Undercoding	Overcoding
Code	Payment	Code	Payment

Total Impact on Claim