2023 Outpatient E/M Audit Tool Guide

To submit this form, please ensure all fields are accurately completed and verified. Submit the completed form via email to audit@healthcare.org, via fax to (123) 456-7890, or through the online submission form on the healthcare organization's website. For physical submissions, mail the completed form to Healthcare Organization, 123 Medical Lane, Suite 456, Healthtown, HT 12345. Ensure you keep a copy of the completed form for your records as well. Additionally, double-check all entered information for accuracy to avoid any delays or issues with processing your submission.

Important dates for using this form include annual updates to E/M coding guidelines, typically occurring in January each year. Make sure to stay updated with the latest guidelines for 2024 and 2025 to ensure compliance.

The purpose of the 2023 Outpatient E/M Audit Tool is to assist healthcare providers and auditors in accurately documenting and coding Evaluation and Management (E/M) services. By following the guidelines and steps outlined in this tool, users can ensure that all relevant patient information, time spent, and medical decision making elements are properly recorded. This not only helps in maintaining compliance with healthcare regulations but also ensures accurate billing and reimbursement for services. Using this tool helps standardize the documentation process, making it easier for providers to meet required standards and avoid common pitfalls in E/M coding. Regular use of the audit tool can also provide valuable insights into practice patterns and areas needing improvement. In summary, the 2023 Outpatient E/M Audit Tool is an essential resource for producing consistent and compliant documentation, thereby supporting overall healthcare quality and efficiency.

• 1. Provider Name & ID:: Contains the name and ID of the healthcare provider.
• 2. Pt. Name:: Contains the patient's name.
• 3. D.O.S.: Contains the date of service.
• 4. Code Billed:: Documents the E/M code billed.
• 5. Chief Complaint:: Contains the nature and severity of the presenting problem.
• 6. Medically appropriate history and exam documented?: Indicates if a medically appropriate history and physical exam are documented.
• 7. Auditor's Code:: Contains the auditor's code.
• 8. Time: Documents the time spent on various activities during the visit.
• 9. Face-to-face visit: Indicates whether a face-to-face visit occurred.
• 10. Circle the Level of Service Based on Total Time Per Documentation: Used to circle the appropriate Level of Service based on the total time documented.
• 11. Elements of Medical Decision Making: Documents the number and complexity of problems addressed as well as the amount and complexity of data to be reviewed and analyzed.

Failing to submit this form can lead to inaccurate billing and potential non-compliance with healthcare regulations.

• Billing Errors: Inaccurate billing due to incomplete documentation can result in denied claims or incorrect reimbursement amounts.
• Non-compliance: Not adhering to documentation standards can result in non-compliance with healthcare regulations and potential legal consequences.

• 1. Conducting Patient Visits: Use the form to document all relevant patient information and time spent during the visit.
• 2. Auditing Outpatient Services: Utilize the form to conduct thorough audits of outpatient E/M services.
• 3. Billing for Services: Accurately complete the form to support proper billing and reimbursement for services provided.