E/M Audit Worksheets

ISBN: 978-1-63012-749-7
  • E/M Audit Worksheets (2 Pages)
  • E/M Audit Worksheets (4 Pages)
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Concise, Reliable, Sturdy, and Re-usable Worksheets to Make Life Easier for Coders & Providers!

Translating your provider’s documentation into the correct evaluation and management code can be a daunting task — and if you miscode by even one level, you’re opening the door to audits and are guaranteeing missed reimbursement. But what if you had a clear, easy-to-read, re-usable worksheet to help you code every encounter?

For providers, the challenge of capturing every detail in the right words to paint an accurate picture for the coder to translate into a code, can be even more challenging. As the saying goes “if it isn’t documented, it wasn’t done.” Providers want to focus on patients, not get bogged down in documentation do’s and don’ts. What if you had a resource that would clearly show your provider how his notes convert to an examination level or E/M level of service?

The E/M Audit Worksheets from the E/M coding experts at TCI are that resource. Useful, handy, and practical tool for coders and auditors helps you:

  • Quickly review the provider’s documentation, homing in on key points.
  • Swiftly determine the overall levels of history, examination, and medical decision making.
  • Accurately assign an overall E/M code for every encounter.
  • That’s not all! We’ve also included an area for coding based on time alone.

This audit tool can be used for coding based on 1995 or 1997 E/M guidelines, and walks you through the E/M coding process from start to finish, for the following encounter types:

  • New and established office/outpatient
  • Consultation
  • Emergency room
  • Initial and subsequent hospital/inpatient
  • Observation
  • Nursing facility
  • Domiciliary
  • Home care.

Bonus: The worksheet really shows how all the pieces of an E/M encounter come together to reach a code, making it ideal for provider education sessions. Coders can use this tool to show providers where their documentation is not matching up to the level of service they feel they are providing to patients. They can show which elements of history, exam, or MDM they need to expand upon in their documentation to support the amount of work they are really doing.

With our expert-tested laminated E/M Audit Worksheets, you can use a dry erase marker or crayon to mark up the worksheets, then erase the marks and reuse the audit tool for the next encounter. Our worksheets are clear and easy to use making life a lot easier for both coders and providers. Choose between a two-page or four-page format, based on whichever works best for your coders and providers.

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