1. finance
2. accounting and auditing

Sample Compliance Audit
Sample Physician Practice
Prepared by Christopher Marsh
on Tuesday, March 1, 2011
Dear Sample Physician Practice;
I would like to thank you for the opportunity to perform this chart audit. This audit has been broken into 1
sections (Evaluation & Management Visits).
Each section will have a summary of our findings as it pertains to that section. Your overall coding quality
score is based on a weighted average. Details about how each code is weighted and how the scoring is
calculated can be found in the whitepaper, "Measuring Coding Quality". I have reviewed the financial
impact of your current coding practices. Based on a comparison of your original coding to the audited
coding, I have inferred the results across your estimated annual volume and have estimated the annual
impact to your revenue.
I have also included a recap of the coding guidelines used during the auditing of each chart. Charts within
each section will be identified by Patient Name and Account Number. Every change from the original
coding will be highlighted and accompanied with an explanatory note.
If you have any questions regarding this audit or any of the details within it, please feel free to contact me.
My phone number is 801-858-3805. Thank you for allowing American Business Systems to be of service. I
hope that we may continue to bring value to your organization.
Best Regards,
Christopher Marsh
Christopher Marsh, MCSD
Chief Information Officer
About American Business Systems:
Paragraph about AuditGuard and ABS.
About Christopher Marsh:
Audit Summary
Audit Summary
Revenue Impact
20 Total Documents Audited
-14.4%
Overcoding
Original coding results were
overcoded, this figure
represents the percentage of
revenue that was overbilled.
Original Revenue:
Audited Revenue:
Change in Revenue:
Est Annual Volume:
Est Annual Revenue Impact:
$6,148
$5,372
$-776
14.4
8,000
$-310,400
Quality Score
85.6
60.4%
This figure represents the
overall accuracy of the original
coding.
37 - Diagnosis Codes Audited
40.5%
Correct:
15
16.2%
Not Coded:
6
43.2%
Miscoded:
16
Miscoded
54 - Procedure Codes Audited
Correct:
40
Not Coded:
0
Miscoded:
6
Undercoded:
2
Overcoded:
6
Miscoded
Charts without Mistakes: 0
74.1%
0.0%
11.1%
3.7%
11.1%
Undercoded
Overcoded
Not Coded
Correct
Correct
Evaluation & Management Visits
Revenue Impact
20 Documents Audited
-14.4%
Overcoding
Original coding results were
overcoded, this figure
represents the percentage of
revenue that was overbilled.
Original Revenue:
Audited Revenue:
Change in Revenue:
Est Annual Volume:
Est Annual Revenue Impact:
$6,148
$5,372
$-776
14.4
8,000
$-310,400
Quality Score
85.6
60.4%
This figure represents the
overall accuracy of the original
coding.
37 - Diagnosis Codes Audited
40.5%
Correct:
15
16.2%
Not Coded:
6
43.2%
Miscoded:
16
Miscoded
54 - Procedure Codes Audited
Correct:
40
Not Coded:
0
Miscoded:
6
Undercoded:
2
Overcoded:
6
Miscoded
Charts without Mistakes: 0
74.1%
0.0%
11.1%
3.7%
11.1%
Undercoded
Overcoded
Not Coded
Correct
Correct
Evaluation & Management Visits
Assumptions:
1995 documentation guidelines were used as it was determined they would give the highest levels.
If the patient status (new vs established) was not documented in the notes we had to assume that the
category of code originally billed was correct.
The complete patient history is not known (including global periods, etc.). This may have affected coding
and modifier usage. Aviacode audited based on documentation sent only. Aviacode audited using CMS
guidelines, realizing that some private payors may require different guidelines.
Overall Audit Findings:
In order for a consultation to meet 99244 you must have a comprehensive history and exam with
moderate medical decision making. All consultations audited were billed as 99244 but did not meet the
requirements for that level.
Diagnosis coded must be documented. Several diagnosis were coded but were not documented.
Diagnosis should be documented to the highest specificity.
The term "unremarkable" is used to describe the exam finding of the head and neck as well as the
extremities on several visits. Auditors view the term unremarkable differently. I would recommend
using negative or normal to avoid having these portions of the exam discredited on future audits.
On cases that 94350 is billed I do not see the results documented in the visit note. I recommend clear
documentation of the testing done and results found.
S9999 has been coded to capture sales tax. Medicare does not accept temporary codes. I did not see
consistency in coding S9999 through out the audit which may be due to specific insurance carriers
accepting this code. Credit was given for S9999 when coded. I recommend verifying the use of S9999.
Reading the Detalied Results:
Any remarks about a specific code will be listed just below the section of codes for that document and
will correspond to the codes line number, like "Px-2". Remarks about the document in general will be
listed as "Doc".
The scoring on each document lists point possible and points earned. This is generated using the scoring
algorithm outlined in the whitepaper, "Measuring Coding Quality".
Coding errors made have been catagorized and are listed under the arrow column.
C = Coded Correctly
N = Not Coded (the original coding did not list this code and it should have)
O = Overcoded (the original coding used a wrong code that resulted in excess revenue)
U = Undercoded (the original coding used a wrong code that resulted in reduced revenue)
M, I = Miscoded (the original coding was incorrect)
Page 6 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
One, Patient
1537
06/24/2010
Doctor Smith
Medica
Christian Eyring
50% (1 Earned, 2 Possible)
Dx-1
Procedures
Original
Audited
511.0
786.52
Original
M
Px-1
99213-1
Audited
$118
99213-1
$118
Dx-1: Pleuritis is documented as presumed. Recommend coding painful respiration 786.52.
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Location • Modifying Factors • Duration • Severity
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Expanded Problem Focused)
Organ Systems (2)
• Respiratory • Constitutional
Body Areas (2)
• Head, Face • Neck
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Moderate)
• Management Option: M - Prescription drug management
99213
Chief Complaint Documented
Yes
C
Page 7 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Two, Patient
1828
09/30/2010
Doctor Smith
Self
Christian Eyring
67% (2 Earned, 3 Possible)
Dx-1
Procedures
Original
Audited
493.90
493.90
Original
C
Px-1
Px-2
99244-1
94060-1
Audited
$152
$0
99243-1
94060-1
$241
$0
Px-1: Price for 99244 is listed as $152.00 on other patients it is $356.00. Also the cost for 94060 is listed as $.01.
Consultation (Office or Other Outpatient Consultation Services)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Signs and Symptoms • Modifying Factors • Duration • Quality
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past • Social
Exam (Detailed)
Organ Systems (5)
• Ears, Nose, Mouth, Throat • Respiratory • Cardiovascular • Constitutional • Musculoskeletal
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Moderate Complexity)
Problem Points (3:Multiple)
• New problem, no workup planned (1)
Data Points (2:Limited)
• Order and/or review tests from medicine section • Order and/or review tests from radiology section
Risk (Moderate)
• Management Option: M - Prescription drug management
99243
U
C
Page 8 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Three, Patient
1004
09/21/2010
Doctor Smith
BC/BS
Christian Eyring
40% (2 Earned, 5 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
516.8
710.4
517.8
Original
M
N
Px-1
Px-2
Px-3
99214-1
94375-1
94720-1
Audited
$178
$90
$96
99213-1
94375-1
94720-1
$118
$90
$96
Dx-1: Other specified alveolar and parietoalveolar pneumonopathies is not documented (516.8). Recommend coding polymyositis (710.4,517.8).
Office or Other Outpatient (Established Patient)
History (Expanded Problem Focused)
HPI (Extended)
• Modifying Factors • Severity • Timing • Signs and Symptoms
ROS (Problem Pertinent)
• Respiratory
PFSH (Pertinent)
• Past
Exam (Expanded Problem Focused)
Organ Systems (2)
• Constitutional • Respiratory
Body Areas (2)
• Head, Face • Neck
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Low)
• Presenting Problem: L - One stable chronic illness
99213
Chief Complaint Documented
Yes
O
C
C
Page 9 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Four, Patient
1189
04/13/2010
Doctor Smith
Medica
Christian Eyring
80% (4 Earned, 5 Possible)
Dx-1
Procedures
Original
Audited
495.9
861.20
Original
M
Px-1
Px-2
Px-3
Px-4
99214-1
94375-1
94720-1
S9999-1
Audited
$178
$90
$96
$5
99214-1
94375-1
94720-1
S9999-1
$178
$90
$96
$5
Dx-1: Acute lung injury is documented (861.20). Documentation does not support (495.9) unspecified allergic alveolitis and pneumonitis.
Office or Other Outpatient (Established Patient)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Modifying Factors • Signs and Symptoms • Location • Severity
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Cardiovascular • Respiratory
Body Areas (7)
• Abdomen • Head, Face • Neck • Right Upper Extremity • Left Upper Extremity • Right Lower Extremity
• Left Lower Extremity
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99214
C
C
C
C
Page 10 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Five, Patient
1044
11/13/2010
Doctor Smith
Preferred One
Christian Eyring
50% (2 Earned, 4 Possible)
Dx-1
Dx-2
Dx-3
Procedures
Original
Audited
466.0
135
466.0
135
517.8
Original
C
C
N
Px-1
99214-1
Audited
$178
99213-1
$118
Dx-3: Lung sarcoidosis is coded as 135 (517.8).
Office or Other Outpatient (Established Patient)
History (Expanded Problem Focused)
HPI (Brief)
• Signs and Symptoms • Duration • Quality
ROS (Extended)
• Constitutional • Respiratory
PFSH (None)
Exam (Detailed)
Organ Systems (3)
• Constitutional • Cardiovascular • Respiratory
Body Areas (2)
• Head, Face • Neck
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Moderate)
• Management Option: M - Prescription drug management
99213
Chief Complaint Documented
Yes
O
Page 11 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Six, Patient
1191
03/06/2010
Doctor Smith
Medicare
Christian Eyring
83% (5 Earned, 6 Possible)
Dx-1
Dx-2
Dx-3
Procedures
Original
Audited
496
799.02
327.23
496
327.23
Original
C
M
C
Px-1
Px-2
Px-3
99214-1
94375-1
S9999-1
Audited
$178
$90
$4
99214-1
94375-1
S9999-1
$178
$90
$4
Dx-2: Hypoxemia (799.02) is not documented.
Office or Other Outpatient (Established Patient)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Severity • Location • Modifying Factors • Signs and Symptoms
ROS (Extended)
• Constitutional • Cardiovascular • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Respiratory • Cardiovascular
Body Areas (7)
• Head, Face • Neck • Abdomen • Right Upper Extremity • Left Upper Extremity • Right Lower Extremity
• Left Lower Extremity
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99214
C
C
C
Page 12 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Seven, Patient
1362
09/20/2010
Doctor Smith
medicare
Christian Eyring
33% (1 Earned, 3 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
466.0
786.2
780.60
Original
M
N
Px-1
99214-1
Audited
$178
99214-1
$178
Dx-1: Acute bronchitis is not documented (466.0). Recommend coding cough (786.2) and fever (780.60) as supported by documentation.
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Location • Modifying Factors • Context • Severity
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Respiratory • Cardiovascular
Body Areas (3)
• Abdomen • Head, Face • Neck
MDM (Moderate Complexity)
Problem Points (3:Multiple)
• New problem, no workup planned (1)
Data Points (0:Minimal)
Risk (Moderate)
99214
• Management Option: M - Prescription drug management
Chief Complaint Documented
Yes
C
Page 13 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Eleven, Patient
1040
01/28/2010
Doctor Smith
Prefered One
Christian Eyring
83% (5 Earned, 6 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
273.4
490
273.4
465.9
Original
C
M
Px-1
Px-2
Px-3
Px-4
99214-1
94375-1
94720-1
S9999-1
Audited
$178
$90
$96
$5
99214-1
94375-1
94720-1
S9999-1
$178
$90
$96
$5
Dx-2: Bronchitis (490) is not documented. Documentation supports respiratory infection (465.9).
Office or Other Outpatient (Established Patient)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Modifying Factors • Signs and Symptoms • Quality • Duration
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (4)
• Constitutional • Cardiovascular • Respiratory • Musculoskeletal
Body Areas (2)
• Head, Face • Neck
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Moderate)
• Presenting Problem: M - One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
99214
C
C
C
C
Page 14 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Fifteen, Patient
1829
11/30/2010
Doctor Smith
Medicare
Christian Eyring
20% (1 Earned, 5 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
793.1
518.3
511.9
Original
M
N
Px-1
Px-2
Px-3
99214-1
94375-1
94720-1
Audited
$178
$90
$96
99214-1
$178
Dx-1: Infiltrates and pleural effiusions are documented. Recommend coding 518.3 and 511.9.
Px-2: Documentation does not support 94375 or 94720
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Modifying Factors • Signs and Symptoms • Severity • Location
ROS (Extended)
• Respiratory • Cardiovascular
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (4)
• Constitutional • Cardiovascular • Respiratory • Musculoskeletal
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Low)
• Presenting Problem: L - One stable chronic illness
99214
Chief Complaint Documented
Yes
C
I
I
Page 15 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Sixteen, Patient
1008
08/16/2010
Doctor Smith
Medicare
Christian Eyring
80% (4 Earned, 5 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
515
515
719.06
Original
C
N
Px-1
Px-2
Px-3
99214-1
94375-1
94720-1
Audited
$178
$90
$96
99214-1
94375-1
94720-1
$178
$90
$96
Dx-2: Left knee swelling is evaluated as a possible result of taking prednisone and would be appropriate to code (719.06).
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Severity • Duration • Signs and Symptoms • Location
ROS (Extended)
• Respiratory • Constitutional • Musculoskeletal
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Cardiovascular • Respiratory
Body Areas (4)
• Abdomen • Left Lower Extremity • Head, Face • Neck
MDM (Moderate Complexity)
Problem Points
(4:Extensive)
• Established problem, stable or improved (1) • New problem, no workup planned (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99214
Chief Complaint Documented
Yes
C
C
C
Page 16 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Nine, Patient
1467
06/17/2010
Doctor Smith
Ucare MA
Christian Eyring
80% (4 Earned, 5 Possible)
Dx-1
Procedures
Original
Audited
496
496
Original
C
Px-1
Px-2
Px-3
Px-4
99214-1
94350-1
94375-1
94720-1
Audited
$178
$65
$90
$96
99214-1
$178
94375-1
94720-1
$90
$96
Px-2: The description for 94350 is : Pulmonary function testing is performed in a pulmonary lab using helium, nitrogen open circuit,or another method
to check lung functions to include residual capacity or residual volume, the volume of air remaining in the lung after a patient exhales. The
physician interprets results. This code applies to the distribution of inspired gas using multiple breath nitrogen washout curves and including
alveolar nitrogen or helium equilibration time. The residual volume is not documented.
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Modifying Factors • Signs and Symptoms • Location • Severity
ROS (Extended)
• Respiratory • Constitutional
PFSH (Pertinent)
• Social
Exam (Detailed)
Organ Systems (4)
• Musculoskeletal • Respiratory • Cardiovascular • Constitutional
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Presenting Problem: L - One stable chronic illness
• Management Option: M - Prescription drug management
99214
Chief Complaint Documented
Yes
C
I
C
C
Page 17 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Seventeen, Patient
1701
09/09/2010
Doctor Smith
Medicare
Christian Eyring
50% (2 Earned, 4 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
446.4
513.0
446.4
786.6
Original
C
M
Px-1
Px-2
99213-1
94375-1
Audited
$118
$90
99214-1
94375-1
$178
$90
Dx-2: Mass of lung is documented (786.6). Lung abscess is not a clear diagnosis
Office or Other Outpatient (Established Patient)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Location • Modifying Factors • Signs and Symptoms • Quality
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Cardiovascular • Respiratory
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (0:Minimal)
Risk (Moderate)
99214
• Presenting Problem: M - One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
U
C
Page 18 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Thirteen, Patient
1074
09/15/2010
Doctor Smith
Medicare
Christian Eyring
50% (2 Earned, 4 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
496
446.4
786.05
Original
M
M
Px-1
Px-2
99214-1
94375-1
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Modifying Factors • Signs and Symptoms • Severity • Timing
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (4)
• Constitutional • Respiratory • Cardiovascular • Musculoskeletal
Body Areas (3)
• Abdomen • Neck • Head, Face
MDM (Straightforward)
Problem Points (1:Minimal)
• Established problem, stable or improved (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Low)
• Presenting Problem: L - One stable chronic illness
99214
Audited
$178
$90
99214-1
94375-1
$178
$90
Chief Complaint Documented
Yes
C
C
Page 19 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Nineteen, Patient
1332
04/28/2010
Doctor Smith
Minnesota Health Care
Christian Eyring
50% (4 Earned, 8 Possible)
Dx-1
Dx-2
Dx-3
Procedures
Original
Audited
486
327.23
786.90
486
327.73
Original
C
M
M
Px-1
Px-2
Px-3
Px-4
Px-5
99244-1
94350-1
94375-1
94720-1
S9999-1
Audited
$356
$65
$90
$96
$9
99243-1
$241
94375-1
94720-1
S9999-1
$90
$96
$9
Dx-3: Documentation does not show support 786.09.
Px-2: The description for 94350 is: Pulmonary function testing is performed in a pulmonary lab using helium, nitrogen open circuit, or another method
to check lung functions to include residual capacity or residual volume, the volume of air remaining in the lung after a patient exhales. The
physician interprets results. This code applies to the distribution of inspired gas using multiple breath nitrogen washout curves and including
alveolar nitrogen or helium equilibration time. Residual capacity is not documented as a result of this test.
Consultation (Office or Other Outpatient Consultation Services)
History (Detailed)
HPI (Extended)
• Context • Location • Duration • Signs and Symptoms
ROS (Extended)
• Constitutional • Cardiovascular • Respiratory
PFSH (Pertinent)
• Past • Social
Exam (Detailed)
Organ Systems (4)
• Constitutional • Cardiovascular • Respiratory • Musculoskeletal
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Moderate Complexity)
Problem Points
(4:Extensive)
• New problem, additional workup planned (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Moderate)
• Management Option: M - Prescription drug management
99243
Chief Complaint Documented
Yes
O
I
C
C
C
Page 20 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Eighteen, Patient
1003
08/05/2010
Doctor Smith
Medicare
Christian Eyring
75% (3 Earned, 4 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
466.0
496
466.0
Original
C
M
Px-1
Px-2
99214-1
94375-1
Audited
$178
$90
99214-1
94375-1
$178
$90
Dx-2: COPD (496) is not documented.
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Location • Duration • Severity • Signs and Symptoms
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (3)
• Constitutional • Cardiovascular • Respiratory
Body Areas (2)
• Head, Face • Neck
MDM (Moderate Complexity)
Problem Points (3:Multiple)
• New problem, no workup planned (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99214
Chief Complaint Documented
Yes
C
C
Page 21 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Fourteen, Patient
1062
03/18/2010
Doctor Smith
Ucare MA
Christian Eyring
67% (2 Earned, 3 Possible)
Dx-1
Procedures
Original
Audited
466.0
491.1
Original
M
Px-1
Px-2
99214-1
S9999-1
Audited
$178
$3
99214-1
S9999-1
$178
$3
Dx-1: Recurrent bronchitis is documented (491.1).
Office or Other Outpatient (Established Patient)
History (Expanded Problem Focused)
HPI (Extended)
• Duration • Severity • Modifying Factors • Signs and Symptoms
ROS (Extended)
• Constitutional • Respiratory
PFSH (None)
Exam (Detailed)
Organ Systems (3)
• Cardiovascular • Respiratory • Constitutional
Body Areas (3)
• Head, Face • Neck • Abdomen
MDM (Moderate Complexity)
Problem Points (3:Multiple)
• Established problem, stable or improved (1) • Established problem, worsening (1)
Data Points (0:Minimal)
Risk (Moderate)
99214
• Presenting Problem: M - Two or more stable chronic illnesses
Chief Complaint Documented
Yes
C
C
Page 22 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Twenty, Patient
1845
10/07/2010
Doctor Smith
BC/BS Federal
Christian Eyring
43% (3 Earned, 7 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
501
794.2
501
793.1
Original
C
M
Px-1
Px-2
Px-3
Px-4
Px-5
99244-1
94350-1
94375-1
94720-1
94664-1
Audited
$356
$65
$90
$96
$28
99243-1
$241
94375-1
94720-1
$90
$96
Dx-2: Abnormal findings lung scan (794.2) is not supported by documentation. The abnormal finding is on an x-ray (793.1).
Px-2: Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time
(94350) is not supported by documentation. Results are not documented.
Px-5: Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device (94664) is not
documented.
Consultation (Office or Other Outpatient Consultation Services)
History (Detailed)
HPI (Extended)
• Signs and Symptoms • Location • Timing • Modifying Factors
ROS (Extended)
• Respiratory • Constitutional
PFSH (Pertinent)
• Past
Exam (Detailed)
Organ Systems (4)
• Constitutional • Respiratory • Cardiovascular • Musculoskeletal
Body Areas (3)
• Abdomen • Head, Face • Neck
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from radiology section
Risk (Moderate)
• Presenting Problem: M - Undiagnosed new problem with uncertain prognosis
99243
Chief Complaint Documented
Yes
O
I
C
C
I
Page 23 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Twelve, Patient
1018
09/13/2010
Doctor Smith
Medicare
Christian Eyring
67% (2 Earned, 3 Possible)
Dx-1
Procedures
Original
Audited
494.0
494.0
Original
C
Px-1
Px-2
Office or Other Outpatient (Established Patient)
History (Detailed)
HPI (Extended)
• Location • Quality • Duration • Context
ROS (Extended)
• Constitutional • Respiratory
PFSH (Pertinent)
• Past
Exam (None)
Organ Systems (0)
Body Areas (0)
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99213
33214-1
94375-1
Audited
$178
$90
99213-1
94375-1
$118
$90
Chief Complaint Documented
Yes
O
C
Page 24 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Ten, Patient
09/30/2010
Doctor Smith
Minnesota Health Care
Christian Eyring
33% (1 Earned, 3 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
496
327.23
327.23
Original
M
C
Px-1
99214-1
Audited
$178
99212-1
$72
Dx-1: COPD (496) is not documented.
Office or Other Outpatient (Established Patient)
History (Problem Focused)
HPI (Brief)
• Context • Location
ROS (None)
PFSH (Pertinent)
• Past
Exam (None)
Organ Systems (0)
Body Areas (0)
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Management Option: M - Prescription drug management
99212
Chief Complaint Documented
Yes
O
Page 25 of 25
Patient:
Account:
Service Date:
Physician:
Payor:
Coder:
Score:
Diagnoses
Eight, Patient
03/08/2010
Doctor Smith
Health Partners
Christian Eyring
83% (5 Earned, 6 Possible)
Dx-1
Dx-2
Procedures
Original
Audited
135
135
517.8
Original
C
N
Px-1
Px-2
Px-3
Px-4
99214-1
94375-1
94720-1
S9999-1
Audited
$178
$90
$96
$5
99214-1
94375-1
94720-1
S9999-1
$178
$90
$96
$5
Dx-2: Lung sarcoidosis is coded as 135 (517.8).
Office or Other Outpatient (Established Patient)
Chief Complaint Documented
Yes
History (Detailed)
HPI (Extended)
• Context • Location • Modifying Factors • Severity
ROS (Extended)
• Gastrointestinal • Constitutional
PFSH (Complete)
• Past • Social
Exam (Detailed)
Organ Systems (4)
• Skin • Cardiovascular • Constitutional • Respiratory
Body Areas (2)
• Head, Face • Neck
MDM (Low Complexity)
Problem Points (2:Limited)
• Established problem, worsening (1)
Data Points (1:Minimal)
• Order and/or review tests from medicine section
Risk (Moderate)
• Presenting Problem: M - One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
• Management Option: M - Prescription drug management
99214
C
C
C
C