ࡱ> []\!` Sbjbj\\ .F>>J  r j(j(j(8((&/pf)f)()))i*i*i*///////$ 1ht3ZA/i*i*i*i*i*A/))V/o+o+o+i*d))/o+i*/o+o+:#,,c,)Z) uj(*^O, ,l/0/Y, 3++.3c,3c,i*i*o+i*i*i*i*i*A/A/Y+i*i*i*/i*i*i*i*&&&Dj(&&&j(2$Vn$  PATIENT IDENTIFIER__________ CODING AUDIT CHEAT SHEET TYPE OF SERVICE PROVIDED: Preventive Health New patient ______ Preventive Health Established patient ______ Counseling Services No Physical Complaint Is time recorded in chart? YES _____ NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit: where counseling determines time Is the total time of the visit recorded YES _____ NO _____ Is the time spent in counseling recorded YES _____ NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit NEW PATIENT Evaluation / Management Visit ESTABLISHED PATIENT CPT & ICD-9 CODES USED CPT CODES ______ ICDE-9 CODES ______ DO THE CPT/ICD-9 CODES COORELATE? ______ ______ YES _____ NO ______ ______ ______ HISTORY AND EXAMINATION New 99201**99202992039920499205Established9920199212992139921499215HPI01144*ROS001210PFSH00012EXAM01458 * or status of at least 3 chronic or inactive conditions CHART AUDIT LEVELS FOR E/M VISITS HPI, ROS, PFSH _____ NEW PATIENT LEVEL ____ NEW PATIENTS: ALL Three are required lowest level determines EXAMINATION _____ ESTABLISHED PT LEVEL ____ ESTABLISHED PATIENTS: Two out of Three determines level MEDICAL DECISION MAKING* _____ (Determine this first) *See next page MEDICAL DECISION MAKING Determine this level first, then verify that chart documentation (HPI, ROS, PFSH & Examination) supports the level Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level. New99201*99202992039920499205Established9921199212992139921499215Diagnoses or Management Problems-One Self-limited or minor problem-Two or more self-limited or minor problems -One stable chronic condition -Acute uncomplicated illness (e.g., allergic rhinitis, simple sprain-One or more chronic illnesses with complications -Two or more stable chronic illnesses -Undiagnosed new prob. w/ uncertain prognosis -Acute illness with systemic symptoms Acute complicated injury-One or more chronic illness with severe complications -Acute or chronic illness or injury that is life or limb threatening -Abrupt change in neurologic statusDiagnostic Procedures (only 2 areas must agree to determine medical decision making level, so this area is not usually the deal breaker as most SBHC do not typically do level 3, 4 or 5 Diagnostics)-Lab -X-ray -EKG -UA -Ultrasound -Venipuncture -KOH.-Physiologic tests not under stress -Pulmonary Function -Barium enema -Arterial puncture -Skin biopsies-Physiologic tests under stress - cardiac stress test -Diagnostic endoscopies with no risk factors -Deep needle or incisional biopsy -Obtained fluid from body -Cardiovascular imaging w/ contrast-Cardiovascular imaging with contrast Invasive diagnostic tests -Cardiac electrophysiological tests -Diagnostic endoscopies w/ identified risk factors -DiscographyTreatment of Management Options-Rest -Gargles -Elastic bandages -Dressings-OTCs -Minor surgery w/ no identified risk factors -PT -OT -IVs without additives-Minor surgery with risk factors -Elective major surgery - no risk factors -Prescription drug management -IV fluids with additives -Closed fracture or dislocation treatment w/o manipulation -Therapeutic nuclear medicine-Elective surgery with identified risk factors -Emergency major surgery -Parenteral controlled substances -Drug treatment requiring intense monitoring -Decisions not to resuscitate or de-escalate care because of poor prognosis * For a new patient 99201, use the requirements for a new patient 99202     PAGE 1 This form shall forevermore be knows as: The Dianne Demers Coding Compliance Cheat Sheet -  PAGE 1 - %&?@Z b z ~ R t  # * > A D c d | ںڬvgh'5CJOJQJ^JaJh'OJQJ^Jh'CJOJQJ^JaJh'>*CJOJQJ^JaJh'5CJOJQJ^JaJh'CJOJQJ^JaJ h'5CJOJQJ\^JaJh'CJOJQJ\^JaJh'5OJQJ\^JaJh'OJQJ\^JaJh'OJQJ\(%&?@Z H I  W X   / $^`a$ $^`a$$a$R/ K a b z ~ $$Ifa$$If$a$ $p0^p`0a$ $p`^p``a$ F@7777 $$Ifa$$Ifkd$$Iflֈ2 dR&bFTFT0#4 la< =7$Ifkd$$Iflֈ2 dR&bFTFT0#4 la< $$Ifa$ =7$Ifkd$$Iflֈ2 dR&bFTFT0#4 la< $$Ifa$ =7$Ifkd$$Iflֈ2 dR&bFTFT0#4 la< $$Ifa$  =7$Ifkd$$Iflֈ2 dR&bFTFT0#4 la< $$Ifa$    =kd$$Iflֈ2 dR&bFTFT0#4 la< $$Ifa$ Q R t u  # c d ; $$Ifa$$If^` :;;`d ;FVuUk"Bou *ȾⰍ𰄀xxxxjh'Uh'h'5OJQJh'5CJOJQJ^JaJ'jh'0JCJOJQJU^JaJh'CJOJQJ^JaJh'OJQJ^Jh'CJOJQJ^Jh'CJOJQJ^JaJh'CJOJQJ^JaJh'5CJOJQJ^JaJ+/)$Ifkd$$Iflֈb HP!|)T8p t0n(4 laz $$If]a$  $$If]a$ $$Ifa$;<_<66666$Ifkd$$Iflֈb HP!|)T8p t0n(4 laz Fu0T $If]$If TUk")<66666$Ifkd$$Ifl ֈbx 5!|)T t0n(4 laz).2>LRv?Y}!  $If]$If!"BCIRd<66666$Ifkd$$Ifl ֈbx 5!|)T t0n(4 lazdou *D4 $If]$If<::8::kd~ $$Ifl ֈbx 5!|)T t0n(4 lazPQRS&`#$CDJKLMPRS̿h'CJOJQJ^JaJh'OJQJmHnHujh'OJQJUh'OJQJh'h'0JmHnHu h'0Jjh'0JU,&P/ =!"#$% $$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$If<!vh5b55F5T5F5T#vb#v#vF#vT#vF#vT:V l0#5b55F5T5F5T4a<$$Ifz!vh5T58555p5#vT#v8#v#v#vp#v:V l t0n(5T58555p54az$$Ifz!vh5T58555p5#vT#v8#v#v#vp#v:V l t0n(5T58555p54az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az8@8 Normal_HmH sH tH @@@ Heading 1$@& CJOJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 4>@4 Title$a$5CJ4 @4 Footer  !.)@. 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