Evaluation and Management Coding Audit Form
Complete this form to document your audit of Evaluation and Management (E/M) coding for a patient visit.
Patient Name
*
First Name
Last Name
Provider Name
*
First Name
Last Name
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Visit
*
Please Select
New Patient
Established Patient
Consultation
Emergency Department
Hospital Inpatient
Hospital Outpatient
Other
CPT Code(s) Billed
*
ICD-10 Diagnosis Code(s)
*
Audit Criteria Scoring
*
Rows
Met
Not Met
N/A
History documented appropriately
1
2
3
Exam documented appropriately
4
5
6
Medical decision making level supported
7
8
9
Time documented (if applicable)
10
11
12
Coding is accurate for documentation
13
14
15
All required elements present
16
17
18
Overall Coding Assessment
*
Correctly Coded
Overcoded
Undercoded
Comments or Recommendations
Auditor Name
*
First Name
Last Name
Audit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Audit
Should be Empty: