# E/M Audit



## sec5188

I am about to begin an E/M audit in our facility.  Does anyone have any pointers or useful audit templates they used?


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## btadlock1

ses5188 said:


> I am about to begin an E/M audit in our facility.  Does anyone have any pointers or useful audit templates they used?



I like Trailblazer's: http://www.e-medtools.com/Aqua_Medicare_Coding_Worksheet.html
I made my own "score sheet" for providers in Excel that allows me to show what I gave credit for including in the exam (We use 1997 guidelines only, at the moment.) - My spreadsheet's not perfect, but it works... I can email it to you tomorrow, if you want.


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## sec5188

Thank you Brandi!  We are also using 1997 guidelines.  That would be great if you could email your score sheet.
sondra.schilke@wku.edu


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## btadlock1

ses5188 said:


> Thank you Brandi!  We are also using 1997 guidelines.  That would be great if you could email your score sheet.
> sondra.schilke@wku.edu



Just sent it!


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## NLS1983

Would it be any trouble if you emailed it to me also? 

shannonl@trinity-health.org


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## btadlock1

If anyone else would like it, just let me know.


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## rthames052006

btadlock1 said:


> I like Trailblazer's: http://www.e-medtools.com/Aqua_Medicare_Coding_Worksheet.html
> I made my own "score sheet" for providers in Excel that allows me to show what I gave credit for including in the exam (We use 1997 guidelines only, at the moment.) - My spreadsheet's not perfect, but it works... I can email it to you tomorrow, if you want.



Hey Brandi:

Would you mind sending me a copy of the score sheet you created.  I'd like to take a peek if you don't mind...

rthames@heritagmedgrp.com

Thanks much!


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## btadlock1

rthames052006 said:


> Hey Brandi:
> 
> Would you mind sending me a copy of the score sheet you created.  I'd like to take a peek if you don't mind...
> 
> rthames@heritagmedgrp.com
> 
> Thanks much!



Just sent it!


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## carolhodge

I would love a copy.   carol.hodge26@yaho.com

Thanks so much


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## SLB1025

I would love a copy as well. Thanks!

boydso@yahoo.com


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## btadlock1

I've sent it to both of you - please let me know if you don't receive it.


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## veloso

Hi Brandi,
Can I have a copy too..pls.and thanks
ireneam@gmail.com


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## pglazener

I would like a copy also please.  pglazener@goodhealthfinancial.com


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## btadlock1

pglazener said:


> I would like a copy also please.  pglazener@goodhealthfinancial.com



I got it to you...

I'd like some feedback from all of you guys (or ladies, I guess I should say ), if possible - do you have any suggestions of anything I could do to improve it, or just make it easier to use? Did I miss anything important that you can see?

Thanks!


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## MnTwins29

*If you don't mind...*

could I please obtain one of your scoring sheets as well?  lsmith3@health-quest.org 

And yes, the guys do this task as well!  

Lance Smith


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## abc1099

We use Intellicode for our Audits.  It's a nice program, easy to use and has a lot of reporting features.   It also has a print out available after each audit that can be used to show the provider.


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## pamasbury

I would love a copy!  pasbury@zoominternet.net


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## ladybird

*Score Sheet*

I would also like a copy sent to me at  lwilks@synergymedical.org

Thank you.
Lynn


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## CC5657

Hi Brandi,
I would also love to have a copy!
Thanks,
kmereo@aol.com


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## btadlock1

KAM5657 said:


> Hi Brandi,
> I would also love to have a copy!
> Thanks,
> kmereo@aol.com



I got it sent to you guys...I'm sure everyone's figured it out by now, but I just noticed that the Excel file opens up to the form that I had completed the example on (Sheet2) - the blank form is on Sheet1. kmereo - I fixed it on yours, so it should be fine. Hope everybody likes it!


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## sue37412

Please email me a copy sue37412@aol.com.
Thank you


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## GaPeach77

Thanks Brandi for that link! It includes a fillable PDF that you can save! Love it! Thanks!

Simone Williams


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## 123smile4me@gmail.com

*May I stilll get a copy ???*

lucy@ruralcommail.com  thank You


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## amy_mousie

*audit form*

Please send me a copy also ;o)

wrightam@sjhlex.org

Thank you so much

Amy Wright, CPC-H, CPC, CCP-H, CCP, CMBS


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## penny48

Brandi 

Can I get a copy of the score sheet please?

pclark@gcrmc.org

Thanks


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## nabernhardt

may I get a copy too please 
nbernhardt@memorialhealthcenter.org
thanks


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## jcee

Would you send me a copy of your score sheet also?  Thank you!

jcoxswc@yahoo.com


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## lostone65

I would like a copy if you are still offering.  

tcox@westsoundortho.com

Thank you!

Tammy


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## tsnider

I too would like to have a copy, thank you very much for the offer!

tsnider@ecommunity.com

Thank you!

Traci Snider, CPC


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## Agemian

*Cemc*

Does anyone know what E&M exam template is used for the CEMC exam.  Is it 1995 or 1997 general multisystem exam or must we use both to determine the level.  I was told the exam uses only the 1995 template.  Does anyone know for sure.


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## rthames052006

I took the exam in 2009 and I took both 95 and 97 with me.  I recall a few questions where it told me to use one or the other and even both.  Take them both.


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## btadlock1

tsnider said:


> I too would like to have a copy, thank you very much for the offer!
> 
> tsnider@ecommunity.com
> 
> Thank you!
> 
> Traci Snider, CPC



I think I've gotten everyone who's asked, but if I missed anybody, please let me know!


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## mhstrauss

Brandi, I would like to get a copy also, if you don't mind   Thanks so much!!


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## btadlock1

mhstrauss said:


> Brandi, I would like to get a copy also, if you don't mind   Thanks so much!!



Sure! Just need your email...


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## mhstrauss

I"m so sorry...still braindead this morning  LOL   it is mstrauss@theneuromedicalcenter.com


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## FTessaBartels

*Official Exam guidelines*



Agemian said:


> Does anyone know what E&M exam template is used for the CEMC exam.  Is it 1995 or 1997 general multisystem exam or must we use both to determine the level.  I was told the exam uses only the 1995 template.  Does anyone know for sure.



I believe the official exam guidelines instruct you to bring BOTH 1995 and 1997 audit tools/ templates with you.  When I took the exam there were a couple of scenarios where you were asked to code based on a specific set of guidelines. In at least one case you had multiple questions on the same note - Q1: code based on 1995 / Q1: code based on 1997.

Good luck

F Tessa Bartels, CPC, CEMC


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## Andrschery

*E/M Audit Tool*

Could I obtain a copy of your tool?
Andrschery@centurytel.net
Thank you,

Cheryl


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## btadlock1

FTessaBartels said:


> I believe the official exam guidelines instruct you to bring BOTH 1995 and 1997 audit tools/ templates with you.  When I took the exam there were a couple of scenarios where you were asked to code based on a specific set of guidelines. In at least one case you had multiple questions on the same note - Q1: code based on 1995 / Q1: code based on 1997.
> 
> Good luck
> 
> F Tessa Bartels, CPC, CEMC



You can bring a copy of the guidelines themselves (which I would strongly recommend), and any audit tool you're comfortable with. My little tool only has 1997 guidelines, because that's all I need, but most tools out there don't make the distinction, or they have areas from both guidelines for you to use on the same form. I took the Trailblazer tool to sit for my exam, and it worked out well for me, so it's just your preference, really. Hope that helps!


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## MnTwins29

*Related question on the CEMC exam*

It states that you can bring an audit tool with you.  My question is if that means one copy/sheet of the tool you usually use, or can you bring more copies - one for each case you will be coding for the exam?

I am taking my CEMC on the 29th.   Feeling confident and ready for it - a change for my usual test anxiety.  Hope this doesn't mean I am overconfident and blow it!

Thanks.


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## MandyFlagg

Could you please send me the audit sheets you use?  I have multiple different ones that I will switch on and off from but none of them seem like they flow well.  I appreciate it, mandyflagg@gmail.com


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## JLeonard5

*audit tool*

Brandy,

Would like a copy as well!! (bushkyds@utma.com)
Thanks 
Jane Leonard


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## ReginaR

Hi..If it is not too much trouble, may I have one too?  Thanks
Regina

billing_tfho@optonline.net


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## vmassey

*audit tool*

Brandy,

could I get a copy of your audit tool please?

Thank you
Vicki

vmassey@toctulsa.com


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## btadlock1

I've been trying to keep up with getting it to everyone who asks, but if I don't happen to respond to you on here in a reasonable amount of time, feel free to email me at brandi.tadlock@umchealthsystem.com and I'll send it to you ASAP.


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## lec121661

*score sheet*



btadlock1 said:


> If anyone else would like it, just let me know.



I would love to get a copy please send to me at crossle@evms.edu

thank you so much


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## vramirez

*Me too!*

Would you mind sending it to me too? Please?

vramirez@wtmedical.com


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## A-SODDY

Can I have a copy too? Thanks.
ababler@wisconsinfertility.com


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## tboback

*Auditing ROS and acceptable phrases*

Can anyone tell me if the following is acceptable?

REVIEW OF SYSTEMS: 10 of 14 systems reviewed and are negative except noted above.

"Above" is talking about Cheif Complaint.  Going back to my class days I remember that if the doctor didn't document specifically we can't assume what systems he is talking about.  

What's your thoughts?


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## MandyFlagg

No that is not acceptable!  CGS put it like this: "when using the "negative" notation, always identify which systems were queried and found to be negative" in a recently published article called Tips for Preventing Most Common Evaluation and Management Service Coding Errors.  Sorry I do not have the link, I just have the printed article.  

I am also getting the same instruction from private insurance carriers.

Hope that helps


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## btadlock1

tboback said:


> Can anyone tell me if the following is acceptable?
> 
> REVIEW OF SYSTEMS: 10 of 14 systems reviewed and are negative except noted above.
> 
> "Above" is talking about Cheif Complaint.  Going back to my class days I remember that if the doctor didn't document specifically we can't assume what systems he is talking about.
> 
> What's your thoughts?



Umm, that's a negative from me as well. What systems were reviewed? How would you know that none of those negatives were 'pertinent' negatives, without knowing which systems are being referred to? If he doesn't feel like taking down the ROS by himself, he should consider having the ancillary staff do it for him. Then all he needs to do is show that he reviewed/confirmed the information, by adding a notation at the bottom like "Symptoms reviewed as listed above" or something like that... Hope that helps!


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## tboback

Thank you Mandy and Brandi you both have been great help!!!  

Here's another question.  

Is a 94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination included with 99284 ER visit?

What's your thoughts?

Tina


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## btadlock1

tboback said:


> Thank you Mandy and Brandi you both have been great help!!!
> 
> Here's another question.
> 
> Is a 94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination included with 99284 ER visit?
> 
> What's your thoughts?
> 
> Tina



Yes, it's included. It would be similar to billing for taking the patient's BP, separately.


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## tboback

*Audit cheat sheet*

I would love a copy as well.  Please send it to tina.boback@msn.com.

Thanks so much!
Tina


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## pscott

Brandi,
Can you email the checklist to me as well?
pscott@barretthospital.org.
Thanks!


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## cynthiabrown

send on to me as well...cbrown@medicalbillall.com  thanks, cyndi


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## btadlock1

*I've posted these other places, but...*

I made this E/M reference chart for the new coders I'm tutoring, and since it's similar to an audit tool, I thought some of you might like it, as well. It's kind of "busy", (okay, really busy) but it encompasses nearly all of the E/M codes' requirements (except the oddballs, like Porlonged Care and Telemedicine)...once you get past the initial shock, it's pretty easy to use.

I hope these pics don't load blurry - I had to transfer them from another post, because I'd saved them on a different computer - if you're not able to see it well after right-clicking and saving them to your computer, let me know, and I'll re-load them...enjoy!


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## espforu

*Auditing Training with Providers*

I have just finished my first group of Audits with my doctors.  I am now trying to set up a training with them to help enforce some of the problems.

Being a new auditor, I am trying to find the best way to figure out where to start.  Some providers are over documenting some are under documenting.  Some have too much in the history based on the presenting problem.  So I am trying to figure where to start.

I know we are under coding our visits (or over documenting) but where to begin I do not know. I am trying to figure what are some of the common problems but this means maybe going back to each audit?   

Any suggestions?


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## cansas

Could you please send  me a copy as well.  I would greatly appreciate it.

criggenbach@mhsystem.org


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## Anita Johnson

*1997 E/M Audit tool*


I would love a copy too.

Thank you.

coder925@gmail.com

Anita


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## FTessaBartels

*E/M University*



espforu said:


> I have just finished my first group of Audits with my doctors.  I am now trying to set up a training with them to help enforce some of the problems.
> 
> Being a new auditor, I am trying to find the best way to figure out where to start.  Some providers are over documenting some are under documenting.  Some have too much in the history based on the presenting problem.  So I am trying to figure where to start.
> 
> I know we are under coding our visits (or over documenting) but where to begin I do not know. I am trying to figure what are some of the common problems but this means maybe going back to each audit?
> 
> Any suggestions?



Get them to sign up for www.emuniversity.com!  The case of the week is emailed in a text, with a link to give you the opportunity to "vote" on the correct code (you only get 4 choices, so at least part of the decision making is done for you). Once you vote, you get an link to the video explanation of the coding.  Peter Jensen MD is a CPC and really focuses on necessary but efficient documentation. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## bkudsk

Would you please send me a copy also?  Thanks!

barbk@mountainfamily.org


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## RonMcK3

*1997 E/M Audit tool*

I would appreciate receiving a copy, too.

rmckenzie5@cfl.rr.com

Thank you very much!


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## HCC12345

It is coming up blurry. Can you email that to me at julie_dale@stanocola.com ?
Thank you!


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## MMadrigal

Brandi, may I get a copy also?  Thanks so much.  MMadrigal@hawaii.rr.com


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## espforu

Thanks, I was reviewing that as well and thought about it.


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## PLONDONM

*Scoresheet*

Please email me a copy. Thanks so much
pmirolo@ohio-ortho.com


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## btadlock1

If I haven't sent it to anyone who requested a copy, please let me know - sorry if I sent it to you twice...


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## dvoegele

*Template*

Pls I'd like a copy
dianna.voegele@jcf.hospital.com


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## sammie06

*scoresheet*

I would love a copy

jmhuth@charter.net

Thank you so much


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## donnaw

*excel sheet*

Hi Brandi,

can you please send me a copy as well?

wdmndnn@yahoo.com

thanks!


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## BABS37

Hi! I know I'm the millionth person to ask but could I also have a copy as well? Thank you sooo much! 

babierman@gmail.com


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## tbsmith415@yahoo.com

Can you send me a copy?

tbsmith415@yahoo.com

Thanks,
Teresa


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## Andrschery

Could you send a copy of your scoring sheet to me at andrschery@centurytel.net thanks in advance for your time Brandi!


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## aprilroc

Brandi...

Could you email me a copy also 

aash@romeortho.com

Thanks!


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## andersont

*spreadsheet*

Could I get one also. tina.anderson2@hma.com


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## snyderk

I would like a copy as well.  Thanks
ksnyder39@yahoo.com


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## cwilson3333

*E/m score sheet*



btadlock1 said:


> I like Trailblazer's: http://www.e-medtools.com/Aqua_Medicare_Coding_Worksheet.html
> I made my own "score sheet" for providers in Excel that allows me to show what I gave credit for including in the exam (We use 1997 guidelines only, at the moment.) - My spreadsheet's not perfect, but it works... I can email it to you tomorrow, if you want.



SEARCHING E/M THREADS.  ARE YOU STILL ABLE TO EMAIL YOUR SCORE SHEET?
IF SO, WOULD GREATLY APPRECIATE.  NEW CPC

Thanks,

cw.lmg@hotmail.com


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## melzinser

*me too, please*

I would like to see your Excel version!  Thanks  mzinser@ohio-ortho.com


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## Dug94Jen

I would lilke a copy of it as well.

jflint@giffordmed.org


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## wilson22

I'd like a copy also..

lwilson@laurelhs.org

Thanks!


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## btadlock1

wilson22 said:


> I'd like a copy also..
> 
> lwilson@laurelhs.org
> 
> Thanks!



Sent it! 

*If anyone else would like a copy of my audit worksheets (or any other resource I've posted), please send me an email directly at brandi.tadlock@umchealthsystem.com

(Please include information as to what you're requesting...I've posted a lot of stuff, in a lot of different threads, so if you're not specific, I may not know what you're asking for...)*

You can reply here, if you want, but I can't guarantee that I'll respond in a timely manner...
I get an email notification whenever someone posts in this thread, but only after the first new post that's added, since the last time I actually opened the thread. The email shows me the comment, so I don't need to open this page, to respond.

But, sometimes, I get several requests at once, because new comments bump the thread up to the top of the forum, where a lot of people see it. If I don't check the thread, I may not realize that there are more requests. 

So, emailing me directly is the best way to contact me. Have a good weekend!


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## lphillips

Can I also get a copy please Brandi? longshot-lori@hotmail.com

Greatly appreciate it!


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## drhoads

If you could send me a copy that would be wonderful.  Thank yo!

Budr1@comcast.net

Deborah Rhoads, CCAT, CPC


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## laureenj

Hi Brandi,

I'd like to get a copy too and put up in the CCO Community area if that is ok with you. 

Laureen@CodingCertification.Org


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## sspksn

Brandi, 

I would love a copy, if you would not mind. Thank you so much!

sspksn@yahoo.com


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## codecrazy

*copy of score sheet*

Could you send me a copy too   codermed@hotmail  Thanks


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## chasarmil

Brandi please send me a copy as well.
robinmilwalnut@yahoo.com

thanks


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## 574coding

could you email me a copy too? 
brunnermk@gmail.com
Thank you!


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## kcrouse

*A copy*

Could I please have a copy.  I would like to see how you are using the score card.

crousek@hanoverhospital.org


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## RLXE2004

I would like to have a copy too. could you please sent it to me.


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## RLXE2004

Do you mind sent it to me too.

rlxe2004@yahoo.com


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## teresa

Could you please email me a copy?  Thank You Teresa
email:  tstout@oddh.org


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## Kristi Petersburg

I would like a copy to please
kristij@imahealthcare.com
thanks


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## drhoads

I would love a copy.  drhoads@gshleb.org

Thanks Brandi!


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## marblearch@peoplepc.com

btadlock1 said:


> If anyone else would like it, just let me know.


I would like it also. Thankyou for your help!

marblearch@peoplepc.com

Jennifer Perry, Medical Manager


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## katymatte

can you send me the cheat sheet also? i know this is an older post.
kmatte@renalassociates.com


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## sjfarnsworth

I'm a little late to this conversation, but would love a copy as well!
sfarn@me.com


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## scicchitanoa

If your MAC happens to be Palmetto they have an electronic E/M scoresheet tool on their website.

http://www.palmettogba.com/internet/eandme.nsf/New?OpenForm


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## Samantha68516

Brandi,

Will you send a copy to me as well, please?

samantha.nigh@cch-neb.com

Thank you for your help!

Samantha Nigh, CPC


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## nichae2000@yahoo.com

Hi Brandy,

Please send me a copy as well......nichae2000@yahoo.com.

Thanks!


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## btadlock1

*Duh, Brandi!*

I think I've finally outsmarted the attachment manager on this thread! (Hooray!)

I have attached a copy of my audit worksheet to this post (it's the zipped file), and I also attached an example, of what it looks like completed. Instructions are below...

Please feel free to contact me with any questions or concerns (ask_brandi@hotmail.com). Enjoy!


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## drhoads

I would like a copy of it also...Thanks

budr1@comcast.net


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## lypece

Thank you Brandi for sharing your audit tool! Your advice on tips to take the cpc exam was very helpful as well for me. I really appreciate all the advice and insight that you have to offer and all the time that you put into helping others, myself included!!


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## btadlock1

lypece said:


> Thank you Brandi for sharing your audit tool! Your advice on tips to take the cpc exam was very helpful as well for me. I really appreciate all the advice and insight that you have to offer and all the time that you put into helping others, myself included!!



Thanks!

For everyone else, I'm not sending out any more copies, but you can now download it from the post above, or in this link: https://www.aapc.com/memberarea/forums/showthread.php?t=82080

Feel free to repost/share it, where ever it would be useful!


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## pkozlowski

I would love a copy, sorry i didnt see the post earlier


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## kseeg23

*Me too*

Could I please get a copy! I need something the providers can actually understand! 

kellyjo.swspc@gmail.com

Thanks!!


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## donniruth

Could I get a copy.  thanks...

donni.whatley@utcclinics.com


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## Coder2hear813

Please forward a copy to sharrison@tampabayhearing.com. Thank you


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## AmandaBriggs

*E/M audit tool*

I, too, would love a copy

abriggs@kh.org

Thanks, Amanda


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## janevaum@gmail.com

*Could I get a copy?*

Could you email a copy as well? billing@drspedi.com
Thanks


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## PatriciaWright

*Score Sheet*

I would love to get your score sheet. Patricia.Wright@tpmgpc.com

Thank you!


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## AmandaBriggs

I would also like a copy 

abriggs@kh.org


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## svalego

*Score Sheet*

Could I get a copy please?

Thanks!

susan.valego@yahoo.com


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## CarolLR

I'd like a copy also, please!

carol.rosol@lnrmc.com


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## ljhaley@gmail.com

Count me in too please, on the score sheet and THANK you for sharing! 
LJHR@Juno.com


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## clss1380

*Score Sheet*

I would like one as well, please!

clss1380@yahoo.com


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## clss1380

*Score Sheet*

I would like one as well, please!

clss1380@yahoo.com


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## sonyablair

*Thanks!*

Thanks for uploading the spreadsheet!  I can't wait to give it a try


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## june1975

I would also love a copy.  Thank you!

june.igcasenza@fhphealth.com


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## june1975

I would also love a copy.  Thank you!

june.igcasenza@fhphealth.com

June Igcasenza,CPC


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