To perform this audit, you will need:

• The medical record for each visit.

• Access to the patient account.

Select 10 patients who have had a procedure and an evaluation and management (E/M) service performed. Complete this form for each patient.

Modifier 25 is used to indicate that a procedure was performed on the same day as a significant, separately identifiable E/M service. Append the modifier to the E/M service. All services billed must be medically necessary. Whether or not to bill the E/M service with a modifier requires some judgment. This audit sheet will help you to assess these claims consistently and correctly.

Patient ID:

Practitioner ID:

Date of service:

Auditor ID:

Date of audit:

Is an office visit documented?

▢ Yes

▢ No

Is a procedure documented?

▢ Yes

▢ No

Does the procedure have a 0-10 day global period?

▢ Yes

▢ No

Is there a history documented?

▢ Yes

▢ No

For a new patient, is a separate exam documented?

▢ Yes

▢ No

Is there an assessment/plan noted in the chart?

▢ Yes

▢ No

Was this the first time that the physician saw the patient for this problem?

▢ Yes

▢ No

Is a second problem addressed during the office visit?

▢ Yes

▢ No

Is the procedure a repeat procedure?

▢ Yes

▢ No

Did the patient return to the office solely to have the procedure done because the physician did not have time to do the procedure on the day of the diagnosis?

▢ Yes

▢ No

Does the E/M portion of the note seem to be all recap of a previously taken history and plan?

▢ Yes

▢ No

Was the minor surgical procedure provided for an obvious, clear problem, such as treatment for warts or simple laceration repair?

▢ Yes

▢ No