Encounter & Code Family Verification
- Correct patient, date of service, provider, and place of service are identified.
- The selected E/M code family matches the documented setting and encounter type.
- New versus established patient status is verified when applicable.
- Initial, subsequent, discharge, consultation, emergency, nursing facility, home, or other category requirements are reviewed as applicable.
- The reported service is eligible for selection by medical decision-making, total time, or another category-specific method.
Medical Decision-Making Overview
- The record clearly identifies the problems evaluated or managed during the encounter.
- The amount and complexity of data reviewed and analyzed are supported.
- The risk of patient management is documented and clinically relevant.
- The reported MDM level is based on the required number of MDM elements.
- No element is credited solely because information appears elsewhere in the record without evidence that it affected the encounter.
Problems Addressed
- Each condition credited toward MDM was evaluated or treated during the encounter.
- The documented status of each problem supports its assigned complexity.
- Stable, worsening, uncontrolled, acute, chronic, and threat-related descriptions are clinically supported.
- Conditions merely listed in the history or problem list are not counted unless addressed.
- The assessment and plan show how each credited problem affected management.
Data Reviewed & Analyzed
- Tests, documents, records, and historian information credited toward data are identified.
- Orders and reviews are not counted twice when the applicable rules treat them as a single data element.
- Independent interpretation is separately documented and is not already included in another reported service.
- Discussion with an external physician or qualified health care professional is documented when credited.
- The data level is calculated using current category-specific E/M requirements.
Risk of Patient Management
- Management decisions are clearly documented.
- Prescription drug management, procedures, hospitalization decisions, or other risk factors are supported by the record.
- Risk is based on the management of the patient, not solely on the seriousness of a diagnosis.
- Social factors affecting management are documented when relevant.
- The documented risk supports the level selected under current E/M guidance.
Time-Based Code Selection
- The selected E/M category permits code selection by time.
- Total qualifying time is documented for the correct date or service period.
- The documented time meets the current threshold for the reported code.
- Only qualifying physician or other qualified health care professional activities are included.
- Separately reported procedures and nonqualifying activities are excluded.
- Shared or split service time is evaluated under current payer and organizational requirements when applicable.
Level-of-Service Validation
- The reported level is supported by MDM, time, or the applicable category-specific requirements.
- History and examination are medically appropriate and support the clinical record, even when they do not determine the level.
- The service is not upcoded based on volume of documentation, template length, or copied text.
- The final code selection is consistent with the documented work and medical necessity.
- Applicable payer, facility, and organizational policies have been considered.
Modifiers & Separately Reported Services
- Modifier 25 is supported by a significant, separately identifiable E/M service when reported with a procedure.
- Modifier 24 is supported by an unrelated E/M service during a postoperative period when applicable.
- Modifier 57 is supported by the decision for major surgery when applicable.
- A separate E/M service is not reported for work integral to another procedure or service.
- Documentation supports all other modifiers and distinct-service reporting.
Documentation Integrity
- The note is authenticated by the responsible professional.
- The assessment and plan are clear, complete, and internally consistent.
- Copied or carried-forward information is clinically relevant and does not inflate the level.
- Contradictory documentation is resolved before final audit determination.
- Amendments, addenda, and late entries comply with organizational policy.
Final Audit Determination
- The audited E/M code is supported as reported.
- A lower or higher level is supported by the documentation.
- A different E/M category or code family is appropriate.
- A modifier correction is required.
- Additional documentation clarification or provider education is recommended.
- The finding, rationale, guideline source, and corrective action are documented.
Audit Finding Classification
☐ Supported as reported
☐ Level correction required
☐ Code family correction required
☐ Modifier correction required
☐ Documentation deficiency
☐ Education opportunity
Auditor reminder: Credit only the work that is documented, applicable to the encounter, and permitted under the current E/M category rules.
Educational Disclaimer
This original educational resource does not reproduce proprietary CPT® tables or code descriptors. Use it with the current CPT® code set and E/M guidance, ICD-10-CM Official Guidelines, CMS instructions, payer policies, contractual requirements, and organizational standards. CPT® is a registered trademark of the American Medical Association.