Description

Why Charts Should Be Audited:

• Increased Accuracy: Ensure services billed correspond with the services and/or level of care provided.
• Reduce Denials: Assist in decreasing the likelihood of claim denials due to the lack of supporting documentation or improper coding.
• Improved Revenue Cycle: Optimize coding and billing practices, leading to better reimbursement.

Our medical chart audit reviews provide comprehensive reviews of clinical documentation to ensure compliance with regulatory requirements and standards, optimize billing practices and improve overall coding/billing practices. We currently offer two types of audits:

E/M only audits per date of service

Complete procedure audit per date of service

Our E/M only audits consist of a review of the documentation provided to ensure that the evaluation and management services billed accurately reflect the services provided. While our complete procedure audits are composed of a review of the documentation provided for ALL services rendered for each date of service submitted for auditing.

Chart Audits Include:

• Review patient charts to ensure proper documentation to support the E/M and/or procedures billed.
• Verify that the E/M code billed aligns with the documentation.
• Verify that the E/M code billed is separate and identifiable from any minor procedures performed on the same day, when applicable.
• Verify procedures billed have the proper supporting documentation.
  Provide recommendations to enhance documentation and optimize coding and billing efficiency when applicable.
• An overview of findings per individual chart/DOS submitted.
• Ability for clients to ask post audit questions for up to 30 days once the audit has been completed.

Whether you choose an E/M audit or a complete chart audit, audits are essential for maintaining high standards of supporting documentation which in turn will assist with compliance and help identify areas for improvement while enhancing overall operational outcomes.