ࡱ>  []NOPQRSTUVWXYZ` bjbjss {~\ \ \ f r r r D  8JLmoooooo$hXr   r r  P0P0P0  r r mP0 mP0P0jr r  &DF2i?p8לB!BdBr P0_5/^8     %Z2dfe Z2 r r r r r r  AUDIT FACE SHEET Provider: Audit No: Resident Involved?YesNoA. CPT Coding Errors A-1: Wrong CPT/HCPCS Code (Downcoded) A-2: Wrong CPT/HCPCS Code (Upcoded, ex: billed consult instead of office visit) = 4 pts A-3: Improper use of modifier (inappropriate, not needed; resulting in upcoding) = 2 pts A-3a: Improper use of modifier, not resulting in upcoding = 0 pts A-4: Service performed and billed - but not a billable event or service (Concurrent care, care within the global period, lack or wrong level of CLIA, etc.) = 4 pts A-5: Service performed but not billed or a zero charge = 0 pts A-6: Service billed but not provided = 6 pts COMMENTS: (Identify finding and explain, e.g. A-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ____________________________________________________________________________ __________________________________________________________________________________________________________________B. CPT Coding Error - Documentation B-1: Insufficient Teaching Physician Documentation to support any code = 6 pts B-2: Insufficient Documentation (Does not support the E/M code) - Upcoded by 1 level = 2 pts B-3: Insufficient Documentation (Does not support the E/M code) - Upcoded by 2 levels = 4 pts B-4: Lack of Documentation to support code (Documentation does not exist) = 6 pts B-5: Needs additional documentation to support the code (excludes E/M services; ex: procedures) = 4 ptsCOMMENTS: (Identify finding and explain, e.g. B-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ C. ICD-9 Errors C-1: Diagnosis reported does not fully describe the condition; additional/underlying diagnosis required; incorrect diagnosis code C-2: ICD-9 code(s) not supported in the documentation = 6 ptsCOMMENTS: (Identify finding and explain, e.g. C-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ D. Other Record Keeping Errors D-1: Wrong or Missing Date of Service (billing date does not match service date) = 2 pt D-2: Health care provider signature missing = 2 pt D-3: Incorrect Place of Service = 2 pt D-4: Service billed under one physician but provided by a different physician = 2 pts D-5: Advance Beneficiary Notice not obtained = 3 ptsCOMMENTS: (Identify attribute, e.g. D-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ (Creighton University 2001 - 2007 PATHOLOGY PROFESSIONAL COMPONENT SERVICES AUDIT FACE SHEET Provider: Audit No.: Resident Involved?YesNoA. CPT Coding Errors A-1: Wrong CPT/HCPCS Code (Downcoded) A-2: Wrong CPT/HCPCS Code (Upcoded)=4 pts A-3: Improper Use of Modifier (inappropriate, not needed; resulting in upcoding) = 2 pts A-5: Service performed but not billed or a zero charge A-6: Service billed but not provided = 6 pts COMMENTS: (Identify attribute, e.g. A-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________B. CPT Coding Error - Documentation B-1: Insufficient Teaching Physician Documentation to support any code = 6 pts B-4: Lack of Documentation to support code (documentation does not exist)= 6 pts B-5: Needs additional documentation to support the code = 4 ptsCOMMENTS: (Identify attribute, e.g. B-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________C. ICD-9 Errors C-1: Diagnosis reported does not fully describe the condition; additional/underlying diagnosis required; incorrect diagnosis code C-2: Lacks medical necessity = 6 pts COMMENTS: (Identify attribute, e.g. C-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ D. Other Record Keeping Errors D-3: Incorrect Place or missing Place of Service = 2 pt D-4: Service billed under one pathologist but provided by a different pathologist = 2 pts D-4: Advance Beneficiary Notice not obtained (and service billed) = 3 pts COMMENTS: (Identify attribute, e.g. D-1) ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ (Creighton University 2003 - 2007 AUDITOR'S WORKSHEET - PATHOLOGY REFERENCE LABORATORY Date of Audit: ______ Date of service selected for Audit: _______ Audit Quarter, CY: _____1st2nd 3rd 4th  **************************************************************************************************** A. Requisition Audit Total Number of requisition selected: ________ Identify the number of requisitions in each category below: Client Billing ____Private Payer ____Medicare _____Medicaid _____ Identify how many requisitions in each category were clean (i.e., complete documentation of patient billing and diagnostic information) Client Billing ____Private Payer ____Medicare _____Medicaid _____ Complete the table below, identifying how many requisitions in each category required additional information. CategoriesClient BillingPrivate PayerMedicareMedicaida. Incomplete billing/diagnostic information requiring client callb. Collection of additional information not adequately documented.c. Miss-filedd. Narrative diagnosis to ICD-9e. Other:f. Other: Note any trend or repetitive occurrence (example: lack of ordering physician, patient face sheets printed prior to DOS, etc.) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ B. Coding Audit Narrative Diagnosis Translated to ICD-9 Code a. Number of Requisitions Selected: _________ b. Number identified as incorrectly translated to ICD-9: _______ (attach copies) 1) Number where ICD-9 does not fully describe condition or more specific diagnosis is available: ___________ c. Percentage: _____ d. Identify where problems are occurring for this issue: _______________________________________________________________________________________________________________________________________________________________ ABN Review a. Number of Medicare requisitions selected: ______ b. Number that failed to have a required ABN: ______ (list findings on separate sheet) c. Percentage: _______ d. How many failed Compliance Checker: ______ e. Of those identified in 2.b above, where any billed to Medicare? Yes No f. If 2.e. is yes, how many: ______ 3. Medical Necessity Review Number of requisitions selected: ______ Number of CPT-4 codes reviewed for all requisitions: ______ Number of CPT-4 codes that lacked medical necessity based on diagnosis provided: ______ (list findings on separate sheet) Percentage (c b): ______ 4. Correct Test(s)/CPT-4 Selected (i.e., panels instead of separate tests, etc.) Number of requisitions selected: ______ Number of CPT-4 codes for all requisitions: _____ Number of incorrectly ordered tests: _____ (list findings on separate sheet). 5. Charge Audit Number of requisitions selected: _____ List each pricing/CPT-4 code in GE that DID NOT match Cerner system:  Auditor: ________________________ Creighton University 2003-2007 Provider Audit Report Sheet Department: Provider: Replace the bracketed information with the encounter audit #, patient name and date of serviceProvider/Coder ResponseAction[Audit#] [Pt. Name] [Date of Service]Findings & Comments from App A/A-2/A-3: CPT Audited: ICD-9(Optional):[Audit#] [Pt. Name] [Date of Service] Findings & Comments from App A/A-2/A-3: CPT Audited: ICD-9(Optional):[Audit#] [Pt. Name] [Date of Service] Findings & Comments from App A/A-2/A-3: CPT Audited: ICD-9(Optional):[Audit#] [Pt. Name] [Date of Service] Findings & Comments from App A/A-2/A-3: CPT Audited: ICD-9(Optional):[Audit#] [Pt. Name] [Date of Service]Findings & Comments from App A/A-2/A-3: CPT Audited: ICD-9(Optional): Provider Signature: ________________________________ Creighton University 2001-2007 E/M, In-Office Procedures and Diagnostic Services 1. Provider's Initials:________ Audit #: ___________ DOS: ________________ 2. Patient's Name and Acct #:__________________ _______________________ 3. Payer:MedicareMedicaidOther Fed.Private/Other4. CPT/HCPCS Code(s):_______________________________________________ 5. If time based, answer the following: a. Is time properly documented?YesNo b. If more than 50% of time is counseling or coordination, are total time and counseling time documented? N/A Yes No6. Are all CPT/HCPCS Code(s) correct?YesNo7. If # 6 is No, what code(s) are incorrect and why?_____________ _____________ _________________________________________________________________ 8. ICD-9 Code(s):_____________________________________________________ 9. Are the ICD-9 codes supported by the documentation? YesNo10. If #9 is No, explain and provide proper ICD-9: _________________________ ______________________________________________________________11. Is a Medicare ABN required?YesNo12. If #11 is Yes, was one obtained?YesNo 13. Were modifiers appropriately used?N/AYesNo 14. If #13 is No, explain: _______________________________________________ 15. Were services provided Incident To (Medicare only)?YesNo16. If #15 is Yes, were Medicares Incident To requirements met?YesNo17. Location where services provided: ______________________________________ 18. Was Place of Service Code correct?YesNo19. Patient Type:NewEstabConsultHospital20. Was a Resident involved?YesNo If #20 is No, go to either Section A now. If #20 is yes, continue to #21. 21. If #20 is Yes, and this was a minor procedure, was Teaching Physician presence documented for the entire procedure? Yes No22. If #20 is Yes, and this involved E/M services, did the Teaching Physician personally document his/her presence and/or participation during the key or critical portions? Yes No23. Were services provided by a resident in a qualified Primary Care Exception Clinic? Yes NoIf Yes, answer the following: Number of Residents supervised by the Teaching Physician at any one time?_____ Was the Teaching Physician involved in other billable activity?____ If no, how was this verified? __________________ Did the Teaching Physician personally document the extent of his/her participation in the review and direction of the services furnished by the resident?______ GO TO SECTIONS A-C, Appendix D to Audit E/M SERVICE NOTES: Auditor's Name: _________________________ Date: ___________________ Copyright2001-2007, Creighton University E/M DOCUMENTATION GUIDELINES History (CC, HPI, ROS and PFSH): Note the Chief Complaint. Circle one item from the four columns to the RIGHT, which best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row for level of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the level of history. CC (Chief Complaint):YesNoColumn 1Column 2Column 3Column 41. History of Present Illness (HPI) EXTENDED ( 4 elements (or 3+ chronic conditions -1997 only)Location Timing Modifying FactorsSeverity Duration Associated Signs and SymptomsQuality ContextBRIEF 1-3 elements2. Review of Systems (ROS)Constitution. ENT GI Musculoskeletal Psychiatric All other systems Eyes Skin Endocrine Hem/Lymph Allerg/Immu NegativeNeurological Cardiovasc. Respiratory GU  N/APROBLEM PERTINENT 1 systemEXTENDED 2-9 systemsCOMPLETE ( 10 systems, or some systems with statement "all others negative"3. Past Medical, Family and Social History (PFSH)*COMPLETE 2 PFSH: Established Office; ER 3 PFSH: New Office; Consults; Admit; Hospital ObservationPast History Family History Social History (See Audit Handbook for more details) N/A  N/A PERTINENT 14. LEVEL OF HISTORYPROBLEM FOCUSED EXPANDED PROBLEM FOCUSEDDETAILEDCOMPREHENSIVE *No PFSH required for: (a) Subsequent hospital care or (b) Subsequent nursing facility care Other Questions to Address If ROS and/or PFSH relied upon was based upon an earlier encounter, is there evidence the physician reviewed and updated the previous information? Yes NoIf the ROS and/or PFSH were recorded by ancillary staff and/or by the patient, is there a notation from the physician supplementing or confirming the information? Yes NoDoes the record reflect any conditions or circumstances, which prevented the physician from obtaining a history from the patient or another source? Yes No B.1. Examination (1995) Body Areas: Head, including the faceNeckAbdomenChest, including breasts and axillaeBack, including spineGenitalia, groin, buttocksEach extremity #____Organ Systems: ConstitutionalEars, nose, mouth and throatEyesCardiovascularGastrointestinalRespiratoryMusculoskeletalHematologic, lymphatic, immunologicGenitourinaryNeurologicalPsychiatricSkinCheck the appropriate box and circle the level of Examination Exam of one body area or organ system related to the problemProblem FocusedLimited exam of the affected body area or organ system and other symptomatic or related organ system(s) Expanded Problem FocusedExtended exam of the affected body area(s) and other symptomatic or Related organ system(s) DetailedGeneral multi-system exam (findings in 8 or more of the 12 organ systems) or complete exam of a single organ systemComprehensive B.2. Examination (1997) General Multi-System Exam or A Single Organ Exam (Eyes; Ears, Nose and Throat; Cardiovascular; Respiratory; Genitourinary; Musculoskeletal; Skin; Neurologic; Psychiatric; and Hematologic/Lymphatic/Immunologic) - Use one of the attached checklists for multi-system or a single organ system exam 1-5 bulleted elements in one or more organ systemsProblem Focused6 or more bulleted elements in one or more organ systemsExpanded Problem Focused2 bulleted elements in at least 6 organ systems/body areas, OR 12 bulleted elements in two or more organ systems/body areas, OR 12 bulleted elements (9 for Eye & Psychiatric) (Single Organ)DetailedAt least 2 bulleted elements in nine (9) organ systems/body areas. All elements in each bolded box and at least 1 element in each unbolded box (Single Organ)Comprehensive Complete either a General Multi-System or Single Organ System "score sheet" (Appendix E) C. Medical Decision Making 1. Number of Diagnoses or Treatment Options: Identify each problem/treatment option mentioned in the record. Enter the number in each of the categories in the second column. Do not categorize the problems if the encounter is dominated by counseling/coordination of care, and duration of time is not specified - then enter 3 in the total box. Problems to Examining PhysicianNumber X Points = ResultsSelf-limited or minor (stable, improved or worsening)1Max = 2 Est. problem (to examining physician); stable; improved1Est. Problem (to examining physician); worsening2New Problem (to examining physician); no additional work-up planned3Max = 3New Problem (to examining physician); additional work-up planned4Multiply number by the points for the TOTAL: _________ Bring total to line 1 in Final Result Table (paragraph 4) 2. Amount and/or Complexity of Data to be Reviewed: For each category, circle the number in the points column and total the points. DATA TO BE REVIEWEDPOINTSReview and/or order of clinical lab tests (one or more)1Review and/or order of tests in the radiology section of CPT (i.e. nuclear medicine and all imaging except echocardiography and cardiac cath) (one or more)1Review and/or order of tests in the medicine section of CPT (i.e., EEG, echocardiography, cardiac cath, non-invasive vascular studies, pulmonary function studies, psychological testing, endoscopy) (one or more)1Discussion of test results with performing physician1Decision to obtain old records and/or obtain history from someone other than patient1Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider2Independent visualization of image, tracing or specimen itself (not simply review of report) only if not separately billed by this provider.2 TOTAL: ________ Bring result to line 2 in Final Result Table (paragraph 4) 3. Risk of Complications and/or Morbidity or Mortality: Circle the appropriate entries in this table. The highest level of risk in any one category (Presenting problem, Diagnostic Procedure(s) ordered or Management Options) determines the overall risk RiskPresenting ProblemDiagnostic Procedures(s) OrderedManagement Options SelectedM I N I M A LOne self-limited or minor problem, e.g. cold, insect bite, tinea corporisLaboratory tests requiring venipuncture Chest X-rays EKG/EEG Urinalysis Ultrasound, e.g. echo KOH prepRest Gargles Elastic bandages Superficial dressings L O WTwo or more self-limited or minor problems One Stable chronic illness (e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury (e.g., cycstitis, allergic rhinitis, simple sprain)Physiologic tests not under stress (e.g., pulmonary function tests) Non-cardiovascular imaging studies with contrast (e.g., barium enema) Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsiesOver-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additivesM O D E R A T EOne or more chronic illnesses with mild exacerbation, progression, or side effects of tx. Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis (e.g. lump in breast) Acute illness with systemic symptoms (e.g. pyelonephritis, pneumonitis, colitis) Acute complicated injury (e.g., head injury with brief loss of consciousnessPhysiologic tests under stress (e.g. cardiac stress test, fetal contraction stress test) Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac cath) Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation with manipulationH I G HOne or more chronic illnesses with severe exacerbation, progression, or side effects of tx Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status (e.g., seizure, TIA, weakness, or sensory loss)Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endocscopies with identified risk factors DiscographyElective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis Other:______________________________________ Bring result to line 3 in Final Result Table (paragraph 4) 4. Final Results for Medical Decision Making: Note results from 1-3 above on this table. If one column contains three circles, draw a line down that column to the bottom row for level of medical decision making. If no column contains three circles, the column with the second circle from the LEFT, identifies the level of medical decision making. 1Number of Diagnoses or Management Options( 1 Minimal2 Limited3 Multiple( 4 Extensive2Amount and complexity of data( 1 Minimal or Low2 Limited3 Moderate( 4 Extensive3Highest RiskMinimalLowModerateHighType of Decision MakingSTRAIGHT-FORWARDLOW COMPLEXITYMODERATE COMPLEXITYHIGH COMPLEXITY ************************************************************************************************ CODING TABLES New outpt; Outpt Consult; Inpt Consult Initial Hospital/Observation (3)HistoryPFEPFDCCHistoryD/CCCExamPFEPFDCCExamD/CC CDec. Mak'gSFSFLMHDec. Mak'gSF/LMH(Time) Outpatient Outpt consult Inpt consult  99201 (10) 99241 (15) 99951 (20)  99202 (20) 99242 (30) 99252 (40)  99203 (30) 99243 (40) 99253 (55)  99204 (45) 99244 (60) 99254 (80)  99205 (60) 99245 (80) 99255 (110) (Time) Int. Hosp. Int. Observ. Observ - Same Day Discharge 99221 (30) 99218 99234 99222 (50) 99219 99235 99223 (70) 99220 99236 Established Office - 2 of 3Subseq. Inpt - 2 of 3HistoryStaffPFEPFDCHistoryPF intervalEPF IntervalD intervalExamPFEPFDCExamPFEPFDDec. Mak'gSFLMHDec. Mak'gSF/LMH(Time) 99211 (5) 99212 (10) 99213 (15) 99214 (25) 99215 (40)(Time) Subseq. Inpt.  99231 (15)  99232 (25)  99233 (35)  Initial Nursing Facility Care - 3 of 3Subsequent Nursing Facility Care - 2 of 3HistoryD or CCCPF intervalEPF intervalD intervalC intervalExamD or CCCPFEPFDCDec. Mak'gSF or LM to HM to HSFLMH99304 993059930699307993089930999310 PF = Problem Focused EPF = Expanded Problem Focused D = Detailed C = Comprehensive SF= Straight Forward L=Low M= Moderate H= High Copyright ( 2001-2007, Creighton University; CPT Copyright American Medical Association, all rights reserved. General Multi-System Examination - 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesInspect conjunctivae and lidsExam pupils and irisesOphthalmoscopic exam of optic discs and posterior segmentsENTExternal inspection of ears and nose Assess Hearing Inspect nasal mucosa, septum and turbinatesOtoscopic exam (external auditory canals & tympanic membranes) Inspect lips, teeth and gumsExam oropharynx; oral mucosa, salivary glands, hard/soft palates, tongue, tonsils & posterior pharynx.NeckExam neck (masses, overall appearance, symmetry, tracheal position, crepitus) Exam thyroid (enlargement, tenderness, mass)RespiratoryAssess respiratory effort (intercostal retractions, use of accessory muscles, etc.)Percussion of chest (dullness, flatness, hyperresonance)Palpate chest (tactile fremitus)Auscultation of lungs (breath sounds, adventitious sounds, rubs)CardiovascularPalpate heart (location, size, thrills)Auscultation of heart, noting abnormal sounds & murmursCarotid arteries (pulse amplitude, bruits)Femoral arteries (pulse amplitude, bruits)Abdominal aorta (size, bruits)Extremities for edema and/or varicositiesPedal pulses (pulse amplitude)Chest (Breasts)Inspect breasts (symmetry/nipple discharge)Palpate breasts & axillae (masses/lumps, tenderness)GI (Abdomen)Examine abdomen with notation of presence of masses or tendernessExamine liver and spleenExamine for presence or absence of herniaExamine (when indicated) anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal massesObtain stool sample for occult blood test when indicatedGU- MaleExamine scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass)Examine penisDigital rectal exam of prostate gland (size, symmetry, nodularity, tenderness)GU-FemalePelvic exam (with or without specimen collection for smears and cultures), includingExamine external genitalia and vaginaExamine urethra (masses, tenderness, scarring)Examine bladder (fullness, masses, tenderness)Cervix (general appearance, lesions, discharge)Uterus (size, contour, position, mobility, tenderness, consistency, descent or support)Adnexa/parametria (masses, tenderness, organomegaly, nodularity)LymphaticPalpate lymph nodes in two or more areas:Neck AxillaeGroinOther: _____________________________MusculoskeletalExamine gait and stationInspect/palpate digits and nailsExamine joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. Such exam of any area includes:Inspect/palpate, with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusionsAssess range of motion with notation of pain, crepitation or contractureAssess stability with notation of any dislocation (luxation), subluxation or laxityAssess muscle strength and tone with notation of any atrophy or abnormal movementsSkinInspect skin and subcutaneous tissue (rashes, lesions, ulcers) Palpate skin and subcutaneous tissue (induration, subcutaneous nodules, tightening)NeurologicTest cranial nerves, noting any deficitsExamine sensation (touch/pin/vibration/proprioception)Examine deep tendon reflexes, noting pathological reflexes (Babinski)PsychiatricDescription of patient's judgment and insightBrief assessment of mental status, includingOrientation to time, place and personRecent and remote memoryMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive Perform all bullets in at least nine organ systems or body areas and document at least two bullets from each of nine areas or organ systems. Cardiovascular - Single Organ Exam: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesInspect conjunctivae and lidsENTInspect teeth, gums & palateExam oral mucosa, noting presence of pallor or cyanosisNeckExam jugular veins (distension; a, v or cannon a waves) Exam thyroid (enlargement, tenderness, mass)RespiratoryAssess respiratory effort (intercostal retractions, use of accessory muscles, etc.)Auscultation of lungs (breath sounds, adventitious sounds, rubs)CardiovascularPalpate heart (location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4)Auscultation of heart, noting abnormal sounds & murmursCarotid arteries (pulse amplitude, bruits)Femoral arteries (pulse amplitude, bruits)Abdominal aorta (size, bruits)Extremities for edema and/or varicositiesPedal pulses (pulse amplitude)Chest (Breasts)GI (Abdomen)Examine abdomen with notation of presence of masses or tendernessExamine liver and spleenObtain stool sample for occult blood test when indicatedGULymphaticMusculoskeletalExamine back with notation of kyphosis or scoliosisExamine gait with notation of ability to undergo exercise testing and /or participation in exercise programsAssess muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements.SkinInspect and/or palpate skin and subcutaneous tissue (stasis dermatitis, ulcers, scars, xanthomas)Neurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Eye - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalHead and FaceEyesTest visual acuity (excluding determining refractive error) Test ocular motility including primary gaze alignmentGross visual field testing by confrontation Inspect bulbar and palpebral conjunctivaeExam ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Exam pupils and irises, including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology Slit lamp exam of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp exam of the anterior chambers including depth, cells, and flare Slit lamp exam of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) Ophthalmoscopic exam through dilated pupils (unless contraindicated) of: Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)ENTNeckRespiratoryCardiovascularChest (Breasts)GI (Abdomen)GULymphaticMusculoskeletalSkinNeurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least nine bullets Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Genitourinary - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesENTNeckExam neck (masses, overall appearance, symmetry, tracheal position, crepitus) Exam thyroid (enlargement, tenderness, mass)RespiratoryAssess respiratory effort (intercostal retractions, use of accessory muscles, etc.)Auscultation of lungs (breath sounds, adventitious sounds, rubs)CardiovascularAuscultation of heart, noting abnormal sounds & murmursExam peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)GI (Abdomen)Examine abdomen with notation of presence of masses or tendernessExamine liver and spleenExamine for presence or absence of herniaObtain stool sample for occult blood test when indicatedGU- MaleInspect anus and perineum Exam (with or without specimen collection for smears and cultures) of genitalia including:Scrotum (lesions, cysts, rashes)Epididymides (size, symmetry, masses)Testes (size, symmetry, masses)Urethral meatus (size, location, lesions, dischargePenis (lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities)Digital rectal exam, including:Prostate gland (size, symmetry, nodularity, tenderness) Sphincter tone, presence of hemorrhoids, rectal massesSeminal vesicles (symmetry, tenderness, masses, enlargementGU-FemaleIncludes at least seven of the following eleven elements identified by bullets:Inspect and palpate breasts (masses, lumps, tenderness, symmetry, nipple discharge) Digital rectal exam including sphincter tone, presence of hemorrhoids, rectal massesPelvic exam (with or without specimen collection for smears and cultures), includingExternal genitalia (appear., hair distrib., lesions) Urethral meatus (size, location, lesions, prolapse)Urethra (masses, tenderness, scarring) Anus and PerineumBladder (fullness, masses, tenderness)Cervix (general appearance, lesions, discharge)Uterus (size, contour, position, mobility, tenderness, consistency, descent or support)Adnexa/parametria (masses, tenderness, organomegaly, nodularity) Vagina (appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)LymphaticPalpate lymph nodes in neck, axillae, groin and /or other locationMusculoskeletalSkinInspect and/or palpate skin and subcutaneous tissue (rashes, lesions, ulcers)Neurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Hematologic/Lymphatic/Immunologic - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)Head and FacePalpate and/or percuss face with notation of presence or absence of sinus tendernessEyesInspect conjunctivae and lidsENTOtoscopic exam of external auditory canals and tympanic membranes Inspect nasal mucosa, septum and turbinates Inspect teeth and gums Exam of oropharynx (oral mucosa, hard/soft palates, tongue, tonsils, posterior pharynx)NeckExam neck (masses, overall appearance, symmetry, tracheal position, crepitus) Exam thyroid (enlargement, tenderness, mass)RespiratoryAssess respiratory effort (intercostal retractions, use of accessory muscles, etc.)Auscultation of lungs (breath sounds, adventitious sounds, rubs)CardiovascularAuscultation of heart, noting abnormal sounds & murmursExam peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)Chest (Breasts)GI (Abdomen)Examine abdomen with notation of presence of masses or tendernessExamine liver and spleenGenitourinaryLymphaticPalpate lymph nodes in neck, axillae, groin and /or other locationMusculoskeletalSkinInspect and/or palpate skin and subcutaneous tissue (rashes, lesions, ulcers)Neurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Musculoskeletal - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesENTNeckRespiratoryCardiovascularExam peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)Chest (Breasts)GI (Abdomen)GULymphaticPalpate lymph nodes in neck, axillae, groin and/or other location.MusculoskeletalExamine gait and stationExamine joints, bones and muscles/tendons of four of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. Such exam of any area includes:Inspect, percuss, and/or palpate, with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusionsAssess range of motion with notation of any pain (straight leg raising), crepitation or contractureAssess stability with notation of any dislocation (luxation), subluxation or laxityAssess muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements NOTE: For the comprehensive level of exam, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of exam, each element is counted separately for each body area. For example, assessing range of motion in two extremities = two bullets.SkinInspect and /or palpate skin and subcutaneous tissue (scars, rashes, lesions, caf-au-lait spots, ulcers) in four of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. NOTE: For the comprehensive level, the exam of all four anatomic areas must be performed and documented. For the three lower levels of exam, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities = two bullets.Neurologic/ PsychiatricTest coordination (finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)Examine deep tendon reflexes, noting pathological reflexes (Babinski) Examine sensation (by touch, pin, vibration, proprioception)Brief assessment of mental status, includingOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Neurological - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesOphthalmoscopic exam of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudeates, hemorrhages)ENTNeckRespiratoryCardiovascularCarotid arteries (pulse amplitude, bruits)Auscultation of heart, noting abnormal sounds & murmursExam of peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)Chest (Breasts)GI (Abdomen)GULymphaticMusculoskeletalExamine gait and stationAssessment of motor function including: Muscle strength in upper and lower extremities Muscle tone in upper and lower extremities (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)SkinNeurologicalEvaluation of higher integrative functions includingOrientation to time, place and personRecent and remote memoryAttention span and concentrationLanguage (naming objects, repeating phrases, etc)Fund of knowledge (awareness of current events, past history, vocabulary)Test the following cranial nerves2nd nerve (visual acuity, visual fields, fundi)3rd, 4th, & 6th nerves (pupils, eye movement)5th nerve (facial sensation, corneal reflexes)7th nerve (facial symmetry, strength)8th nerve (hearing with tuning fork, whispered voice and/or finger rub9th nerve (spontaneous or reflex palate movement)11th nerve (shoulder shrug strength)12th nerve (tongue protrusion)Examine sensation (by touch, pin, vibration, proprioception)Examine deep tendon reflexes in upper and lower extremities, noting pathological reflexes (Babinski)Test coordination (finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children).PsychiatricProblem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Psychiatric - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)Head and FaceEyesENTNeckRespiratoryCardiovascularChest (Breasts)GI (Abdomen)GULymphaticMusculoskeletalExamine gait and stationAssessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movementsExtremitiesSkinNeurologicalPsychiatricDescription of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perseveration, paucity of language) Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation. Description of associations (eg, loose, tangential, circumstantial, intact) Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions. Description of the patient's judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition) Complete mental status exam, including: Orientation to time, place and person. Recent and remote memory Attention span and concentration Language (eg, naming objects, repeating phrases) Fund of knowledge (eg, awareness of current events, past history, vocabulary) Mood and affect (eg, depression, anxiety, agitation, hypomania, lability) Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least nine bullets Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Respiratory - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)EyesENTInspect nasal mucosa, septum and turbinatesInspect teeth and gumsExamine oropharynx (oral mucosa, hard/soft palates, tongue, tonsils & posterior pharynx).NeckExamine neck (masses, overall appearance, symmetry, tracheal position, crepitus) Examine thyroid (enlargement, tenderness, mass) Examine jugular veins (distension; a, v or cannon a waves)RespiratoryInspect chest, noting symmetry and expansion Assess respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement)Percussion of chest (dullness, flatness, hyperresonance)Palpate chest (tactile fremitus)Auscultation of lungs (breath sounds, adventitious sounds, rubs)CardiovascularAuscultation of heart, noting abnormal sounds & murmursExamine peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)Chest (Breasts)GI (Abdomen)Examine abdomen with notation of presence of masses or tendernessExamine liver and spleenGULymphaticPalpate lymph nodes inneck, axillae, groin and/or other locationMusculoskeletalExamine gait and stationAssess muscle strength and tone (flaccid, cog wheel, spastic), noting any atrophy and abnormal movementsExtremitiesInspect and palpate digits and nails (clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)SkinInspect and/or palate skin and subcutaneous tissue (eg, rashes, lesions, ulcers)Neurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Skin - Single Organ: 1997 Guidelines System/Body AreaElements (Bullets)ConstitutionalVitals (3of 7):Sitting/Standing BPSupine BPRespirationWeightHeightTemperaturePulse rate & regularityGeneral appearance of patient (development, nutrition, body habitus, deformities, grooming)Head and FaceEyesInspect conjunctivae and lidsENTInspect lips, teeth and gums Exam of oropharynx (oral mucosa, hard/soft palates, tongue, tonsils, posterior pharynx)NeckExam thyroid (enlargement, tenderness, mass)RespiratoryCardiovascularExam peripheral vascular system by observation (swelling, varicosities) and palpation (pulses, temperature, edema, tenderness)Chest (Breasts)GI (Abdomen)Examine liver and spleenExam of anus for condyloma and other lesionsGULymphaticPalpate lymph nodes in neck, axillae, groin and /or other locationExtremitiesInspect and palpate digits and nails (clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)SkinPalpate scalp and inspect hair of scalp, eyebros, face, chest, pubic area (when indicated) & extremities Inspect and/or palpate skin and subcutaneous tissue (rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following 10* areas:Head, including faceNeckChest, including breasts and axillaeGenitalia, groin, buttocksAbdomenBackRight Upper ExtremityLeft Upper ExtremityRight Lower ExtremityLeft Lower Extremity*NOTE: For the comprehensive level, the exam of at least eight anatomic areas must be performed and documented. For the three lower levels of exam, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis.Neurological/Brief assessment of mental status, includingPsychiatricOrientation to time, place and personMood and affect (depression, anxiety, agitation)Problem Focused: One to Five bullets Expanded Problem Focused: At least six bullets Detailed: At least twelve bullets in two or more body areas/organ systems Comprehensive: Perform all bullets; document every bullet in each box with a bolded border and at least one element in each box with an unbolded border. Audit Worksheet - Operations/Procedures/OB Deliveries 1. Provider's Initials:______ Audit #: _____ DOS: ____________ 2. Patient's Name & Acct. #:________________ _________________________ 3. Payer:MedicareMedicaidOther Fed.Private/Other4. CPT/HCPCS Code(s) Billed:_____________________________________________ 5. Are all CPT/HCPCS codes correct?YesNo6. If #5 is No, what code(s) are incorrect and why? ____________________________ ___________________________________________________________________ 7. ICD-9/Diagnoses Listed:_______________________________________________ 8. Are the ICD-9 codes supported by the documentation? YesNo9. If #8 is No, explain and provide proper ICD-9: _______________________________ ___________________________________________________________________ 10. Is a Medicare ABN required? YesNo11. If #10 is Yes, was one obtained? YesNo12. Were modifiers appropriately used?N/AYesNo13. If #12 is No, explain: __________________________________________________ 14. Type of Service Provided: Surgery/Endoscopic OperationDiagnostic Endoscopy OB Delivery15. Was a Resident involved in the procedure?YesNo16. If #15 is No, STOP. If yes, continue to #17.17. Was Teaching Physician (TP) presence documented?YesNo18. If OB delivery and global delivery code was billed, is there documentation that the TP was present during the pre and post partum for the minimum number of visits? Yes No19. TP was present during the:Entire Procedure Go to #22Key portions of 1 or 2 overlapping procedures Go to #20 20. If TP was present during the key portions of one or two overlapping procedures, were the key portions documented by the TP?  Yes No21. Was another physician identified as immediately available during the key portions? Yes No22. Did TP document presence during one or more post-operative visits?  Yes No23. For diagnostic scope procedures, does the documentation reflect that the TP was present during insertion, viewing and removal of the scope? N/A Yes No Auditor's Name: ___________________________ Date: ______________ Copyright ( 2001-2007, Creighton University NOTES Auditors' Worksheet - Psychiatry (Not E/M) 1. Provider's Initials:____________ Audit # ___________ DOS: ___________ 2. Patient's Name & Acct.#:______________________________________________ 3. Payer:MedicareMedicaidOther Fed.Private/Other4. CPT/HCPSC Code(s) Billed on DOS:______________________________________ 5. Are all CPT/HCPCS Code billed correct, including time? YesNo Time In: ________Time Out: _________Total Time: _____________6. For non time based psychiatry services, is there sufficient documentation to support the code, according to payer/CPT standards? YesNo7. If #s 5 or 6 are No, what codes(s) should or should not have been billed and why? ____________________________________________________________ 8. ICD-9 Listed:_________________________________________________ 9. Are the ICD-9 codes supported by the documentation? YesNo10. If #9 is No, explain and provide proper ICD-9: ________________________________________________________________11. Were modifiers appropriately used?N/AYesNo12. If #11 is No, explain?______________________________________________13. Was a Resident involved?YesNo14. If #13 is yes, for Medicare and non-waived payers did the Teaching Physician personally document his/her presence and/or participation during the key portions? Yes No15. If group psychotherapy, is medical necessity documented?YesNo16. If teaching physician is supervising a resident under University waiver (i.e. Medicaid, etc.) has teaching physician reviewed the patient encounters within the time period(s) required by the payer? What is the time period? _______________ Yes No IF THE PROVIDER IS A CLINICAL PSYCHOLOGIST AND THE PAYER IS MEDICARE, ANSWER THE FOLLOWING QUESTIONS. 17. Did the Provider document that he/she informed the patient of the desirability of conferring with the patients attending or PCP to consider potential medical conditions contributing to the patients condition? Yes No18. If the patient consented, did the provider consult the patients attending or PCP? Yes No19. If #18 is yes, did the provider consult with the patients physician within a reasonable time after receiving consent? Yes No Auditor's Name: ________________________ Date: _______________ Copyright ( 2001-2007, Creighton University NOTES AUDITOR'S WORKSHEET - RADIOLOGY 1. Physician's Initials:_______ Audit # _____ DOS: _____________ Patient Name & Acct. No.:__________________________________ 3. Payor:MedicareMedicaidOther Fed.Private4. CPT/HCPCS Code(s) Billed:____________________________________________ 5. Are all CPT/HCPCS Code correct?YesNo6. If #5 is No, what code(s) are incorrect and why? ____________________________ __________________________________________________________________ 7. Diagnosis/ICD-9 codes listed: _______________________________________ 8. Are the ICD-9 codes supported by the documentation?YesNo9. If #8 is No, explain and provide proper ICD9: ______________________________ __________________________________________________________________ 10. If the procedure required the service of a surgeon in addition to the radiologist, was either modifier "-66" or "-62" used?  Yes No11. Were modifiers appropriately used?YesNo12. If #11 is No, explain:________________________________________________ 13. Is a Medicare ABN required?YesNo14. If #13 is yes, was one obtained?YesNo15. Is there a written report of the interpretation?YesNo16. Is the teaching physician's signature the only one on the interpretation? If yes, stop here. Yes No17. Did a resident dictate the report?YesNo18. If #17 is yes, does the documentation indicate that the teaching physician personally reviewed the image and the resident's interpretation and either agrees with or edits the findings? Yes No Auditor's Name: __________________________ Date: ____________ Copyright ( 2001-2007 Creighton University NOTES AUDITOR'S WORKSHEET - ANESTHESIOLOGY A. General Information 1. Physician's Initials: _______ Audit #:______ DOS: _______ 2. Patient's Name & Acct #_______________________________ 3. Payer:______________________________ 4. CPT code(s) billed:_____________________________________________ 5. Are all CPT/HCPCS codes correct?YesNo6. If #5 is No, what code(s) are incorrect and why? _________________________ ________________________________________________________________ 7. ICD-9/Diagnoses Listed:_____________________________________________ 8. Are the ICD-9 codes supported by the documentation?YesNo9. If #8 is No, explain and provide proper ICD-9: ___________________________ _____________________________________________________________________ 10. As applicable for this service, please identify the following: Start: _______ Stop: _________ Total time: _______________ 11. Were services:Personally ProvidedMedically DirectedNon-medically Directed CRNA12. Physical status modifier used ____________ 13. If P-3 or higher, is supporting diagnosis/condition listed in documentation? YesNoIf No, mark C-2.14. Other Modifier(s). What modifier(s), if any, were used? ___________________ Were they appropriate? YesNo If No, mark A-3 and provide modifier(s) that should have been used?__________Why?__________________________________________ 15. Did the anesthesiologist perform the entire, single anesthesia service alone? If yes, proceed to Section B Yes No16. If #15 is No, was the Anesthesiologist involved in one case (1/1) with H.O.? Yes No If #16 is No, proceed to question #18 to address medical direction issues. 17. If #16 is Yes, and a H, O. is involved, is there sufficient documentation that the Anesthesiologist was physically present during, or participated in, all critical (or key) portions of the procedure including induction and emergence?YesNo If #17 is No, stop here and mark B-1. If #17 is Yes, proceed to Part B. MEDICAL DIRECTION (Do not answer if #16 is Yes.) 18. Did the Anesthesiologist medically direct qualified individuals (CRNA's or residents) involved in concurrent cases? Yes No19. If #18 is yes, did the Anesthesiologist medically direct >4 cases? If Yes, mark A-4 if billed. Yes No20. If #18 is Yes, please identify how many? ____. List the times of all concurrent procedures below and then proceed to Part B.M. R. #Start TimeEnd Time  H.O./CRNAProcedure Under Audit 2nd Procedure3rd Procedure4th Procedure B. Documentation Were the services: Personally performed?Medically Directed?Does the Documentation reflect (as applicable) that the Anesthesiologist: 1. Performed the pre-anesthetic exam and evaluation?YesNo2. Prescribed the anesthesia plan?YesNo3. Personally participated in the most demanding procedure in the anesthesia plan, including induction and emergence, if applicable? Yes No4. Ensured that any procedures in the anesthesia plan that the Anesthesiologist did not perform were performed by a qualified individual? (Medical Direction Only) Yes No5. Monitored the course of anesthesia administration at frequent intervals? (Medical Direction Only) Yes No6. Remained physically present and available for immediate diagnosis and treatment of emergencies? (Medical Direction Only) Yes No7. Provided indicated post-anesthesia care?YesNoAnswer only if the services were provided by a non-medically directed CRNA. Does the documentation reflect that the CRNA: 8. Performed the pre-anesthetic exam and evaluation?YesNo9. Prescribed the anesthesia plan?YesNo10. Personally participated in the most demanding procedure in the anesthesia plan, including induction and emergence, if applicable? Yes No11. Provided indicated post-anesthesia care?YesNoIf any answer in this section B is No, mark B-5. C. Other Items 1. Did another Anesthesiologist/Non-medically directed CRNA take over during the procedure(s)? YesNo2. If #C.1 is Yes, was this documented with a stop time for the replaced Anesthesiologist/CRNA and start time for the new Anesthesiologist/CRNA? If No, mark B-5. Yes No3. If #C.1 is Yes, were the services reported for the Anesthesiologist/CRNA who was involved in more than 50% of the case/medical direction period? If No, mark D-5. Yes No4. Did the Anesthesiologist perform any other services while providing medically directed services? Yes No5. If #C.4 is Yes, and these services were billed, were they an emergency of short duration or labor epidural/caudal? If no, mark A-4.  Yes No6. Were any billable services provided that were not billed? If Yes, mark A-5. Yes No7. Were any services billed, but not documented as being provided? If Yes, mark A-6. Yes No Auditors Name_______________________ Date____________________ Copyright ( 2001-2007, Creighton University CMS SCENARIO #1 - E/M Services The Teaching Physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently. No Resident Note. In the absence of a note by a resident, the Teaching Physician must document as he/she would document an E/M service in a non-teaching setting. Resident Note. Where a resident has written notes, the Teaching Physician's note may reference the resident's note. The Teaching Physician must document that he/she performed the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient. Examples of Minimally Acceptable Documentation Admitting Note: "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care." Follow-up Visit: "Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note." Follow-up Visit: "Hospital Day #5. I saw and examined the patient. I agree with the resident's note, except the heart murmur is louder, so I will obtain an echo to evaluate." NOTE: In any of these situations, if there are no resident's notes, the Teaching Physician must document as he/she would document an E/M service in a non-teaching setting. CMS SCENARIO #2 - E/M Services The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In this case, the Teaching Physician must document that he/she was present during the performance of the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient. The Teaching Physician's note should reference the resident's note. For payment, the composite of the Teaching Physician's entry and the resident's entry together must support the medical necessity and the level of the service billed by the Teaching Physician. Examples of Minimally Acceptable Documentation: Initial or Follow-up Visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note." Follow-up Visit: "I saw the patient with the resident and agree with the resident's findings and plan." CMS SCENARIO #3 - E/M Services The resident performs some or all of the required elements of the service in the absence of the Teaching Physician and documents his/her service. The Teaching Physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, the Teaching Physician must document that he/she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The Teaching Physician's note should reference the resident's note. For payment, the composite of the Teaching Physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the Teaching Physician. Examples of Minimally Acceptable Documentation: Initial Visit: "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs." Initial or Follow-up Visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note." Follow-up Visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plan as written." Follow-up Visit: "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI of L/S Spin today." CMS EXAMPLES OF UNACCEPTABLE TEACHING PHYSICIAN DOCUMENTATION "Agree with above.", followed by legible countersignature or identity. "Rounded, Reviewed, Agree.", followed by legible countersignature or identity. "Discussed with resident. Agree.", followed by legible countersignature or identity. "Seen and agree", followed by legible countersignature or identity. "Patient seen and evaluated", followed by legible countersignature or identity. A legible countersignature or identity alone. This type of documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement in the plan of care. Departmental Audit Report Summary Sheet Quarter Audited: ( First ( Second (Third ( Fourth Department: ________________________________________________________ Providers audited: (Last name, First name initial)  Unique/outstanding findings which might indicate a pattern and/or suggest additional review: __________________________________________________________________ __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________ Corrective actions necessary due to findings for this quarter: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Corrective actions completed for previous quarter(s): ProviderQuarter Type of ActionDate Completed Charge tickets reviewed/verified for each provider/area audited? ( Yes ( No Pathology only: Was an OIG sanction check completed? (Yes ( No Other notes: _________________________________________________________________ _________________________________________________________________ (Attach additional information as necessary) Seven Elements of a Medicare IPPE Element 1: Review the beneficiarys medical and social history with attention to modifiable risk factors for disease. Medical History. At a minimum, this must include: Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries and treatments. Current medications and supplements, including calcium and vitamins. Family history, including a review of medical events in the beneficiarys family, including diseases that may be hereditary or place the individual at risk. Social History. At a minimum, this must include: History of alcohol, tobacco, and illicit drug use. Diet. Physical Activities. Element 2. Review the beneficiarys potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the provider may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations. Element 3. Review the beneficiarys functional ability and level of safety based on the use of appropriate screening questions or a screening questionnaire, which the provider may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. This review must include, at a minimum, a review of the following areas: Hearing impairment. (Excludes diagnostic hearing tests, which are separately covered under Medicare). Activities of daily living. Falls risk. Home safety. Element 4. An exam, to include measurement of the beneficiarys height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiarys medical and social history, and current clinical standards. Element 5. Performance and interpretation of an electrocardiogram. This screening electrocardiogram can be referred to another practitioner for performance and/or interpretation. If the provider does not perform or interpret the ECG, then he/she would only bill the G0344 code, but would still need to incorporate the results of the EKG into the beneficiarys medical record to complete the IPPE. The provider of the IPPE related EKG would report one of the following: (i) G0366 (tracing and interpretation), (ii) G0367 (tracing only), or (iii) G0368 (interpretation and report only) Element 6. Education, counseling, and referral, as deemed appropriate by the provider, based on the results of the review and evaluation services as outlined above. Element 7. Education, counseling, and referral, including a brief written plan such as a checklist provided to the beneficiary for obtaining the appropriate screening and other preventive services that are separately covered by Medicare.  For a single procedure, the TP present for the key portions can be immediately available during the rest of the procedure.     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