CDEO cheat sheet

Required note elements: date of service, patient identification, chief complaint/reason for visit, relevant history, examination findings, assessment, plan, and the author's legible signature with credentials.

For 2021 office/outpatient E/M, the level is chosen by medical decision making OR total time on the date of the encounter; history and examination are no longer scored elements.

Total time includes face-to-face and non-face-to-face activities performed by the billing provider on the encounter date: 99213 = 20-29 minutes, 99214 = 30-39 minutes, 99215 = 40-54 minutes.

MDM is supported when at least two of three elements are met: number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications or morbidity.

Problem levels: minimal, self-limited/minor, low (stable chronic or acute uncomplicated illness), moderate (undiagnosed new problem with uncertain prognosis, chronic illness with exacerbation), high (threat to life or bodily function).

Risk levels: minimal, low (over-the-counter drugs, rest), moderate (prescription drug management, minor surgery with identified risk), high (drug therapy requiring intensive monitoring, emergency major surgery, decision regarding hospitalization).

Extended HPI = 4 or more elements (location, quality, severity, duration, timing, context, modifying factors, associated signs). Complete ROS = 10+ of 14 systems, or 2+ systems plus 'all other systems negative.'

ROS and past/family/social history may be recorded by ancillary staff or patient questionnaire; the HPI must be documented by the billing provider.

Amendments must be dated, timed, signed, and preserve the original entry; backdating, deleting prior text, and copy-pasted identical notes across encounters are compliance red flags.

Modifier 25 reports a significant, separately identifiable E/M service by the same provider on the same day as a procedure; the note must show a distinct indication, findings, and plan for the E/M.

NCCI procedure-to-procedure edit modifier indicator 0 means no modifier can override the edit; indicator 1 means a modifier may bypass the edit when clinically appropriate.

Global surgical package: 000 days (minor, no postoperative care), 010 days (minor with follow-up), 090 days (major procedure); the global period begins the day of surgery.

Medicare incident-to billing requires an established patient, a service that is part of the physician's established plan of care, direct supervision, and no new problem being addressed.

Teaching physician rules: resident or student documentation of history, exam, and ROS may be used if verified by the physician; medical decision making must be personally documented by the teaching physician.

ICD-10-CM: code to the highest level of specificity; 'Excludes1' means the two codes are never reported together, 'Excludes2' means not included but may be reported together, and 'code also' signals a required additional code.

Seven compliance program elements: written policies and procedures, designated compliance officer, effective training and education, open lines of communication, internal monitoring and auditing, enforcement of standards, and corrective action.

Both overcoding and undercoding are compliance exposures; only codes supported by the documentation may be reported, regardless of payment impact.

Timed codes billed in units (e.g., therapy) use the 8-minute rule: total timed minutes are divided into 15-minute units, with remaining minutes of 8 or more counting as a unit.

The CMS-HCC risk score expresses expected cost relative to a population average of 1.0; scores above 1.0 predict higher-than-average future healthcare expenditure.

Hierarchies count only the highest-ranked condition within a related family of hierarchical condition categories; lower-ranked conditions in the same hierarchy do not add payment weight.

Chronic conditions must be re-documented and re-coded each calendar year to remain in the risk score; a prior-year diagnosis alone does not carry forward.

MEAT is the documentation evidence that supports a chronic condition: monitoring, evaluating, assessing, or treating the condition during the encounter.

Diagnoses cannot be reported from lab results, medication lists, problem-list entries, or implied/suspected conditions unless the provider documents the condition as present.

RADV audits validate diagnoses submitted for Medicare Advantage payment against the medical record; unsupported diagnoses are recouped.

HEDIS measures such as CDC (HbA1c control), CBP (blood pressure control), BCS (breast cancer screening), and COL (colorectal cancer screening) are calculated largely from claims and encounter data.

MIPS performance category weights: Quality 30%, Cost 30%, Promoting Interoperability 25%, Improvement Activities 15%.

Accurate diagnosis coding drives both risk-adjustment payment accuracy and quality measure performance, so documentation gaps affect two revenue streams at once.

Effective feedback is timely, specific, evidence-based, and directed at the documentation behavior rather than at the individual clinician.

Queries must be non-leading: present the clinical facts and request clarification without suggesting a diagnosis, code, or finding the provider has not documented.

Query responses become part of the medical record and must be retained with the encounter; retrospective diagnoses cannot be added solely to support a code.

Cite an authoritative source in education and feedback: CPT Assistant, ICD-10-CM Official Guidelines for Coding and Reporting, CMS manuals, and payer medical policies.

Measure before and after education: error rate by provider and code family, E/M level distribution, query response rate, and denial rate by reason code.

Adult learning principles: education is most effective when problem-centered, immediately applicable to the provider's practice, and built from their own de-identified audited cases.

Document each education session with date, audience, topics covered, materials used, and acknowledgement to evidence an ongoing compliance program.

Protect PHI: use secure portals for record exchange, de-identify audit examples, and avoid transmitting patient identifiers through unsecured email.