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Last Modified 10/31/2008

Medicare E & M Service Coding and Audit Worksheet  

The FREE Medicare Evaluation and Management (E&M) Coding and/or Audit Worksheet can help determine the appropriate level of service for medical care provided.  This worksheet was developed using the methods of Medicare carriers in most states, and is  a fillable PDF form.  This allows your work to be saved for future reference in an electronic format.   This worksheet is also available in an Aqua Theme.



The FREE Medicare Evaluation and Management (E&M) Coding and/or Audit Worksheet has scoring tools for the history, exam, and medical decsion making elements that are required for all E&M encounters.  This worksheet includes scoring tools for the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services published by Medicare.

The E&M Coding/Audit Worksheet uses the method outlined in "Thinking on Paper: Guidelines for Documenting Medical Decision Making" by Robert L. Edsall and Kent J. Moore  and the HGSA documentation worksheet.  This method is used by most Medicare carriers.  

References for the E&M Coding/Audit Worksheet

Important Note

Health care providers in Delaware, Maryland, Texas, Virginia, or the District of Columbia must used the method developed by Trailblazer Health, the local Medicare Carrier,  to determine the complexity of Medical Decsion Making.  

Trailblazer Health documentation worksheet

MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.