Surgical Chart Auditing

Overview:

We will explore auditing surgical procedures for physician services. Understand CPT and CMS Surgery Guidelines along with Modifiers, assessing the diagnosis code to support medical necessity and evaluating and rating the Surgical Medical Record. Scoring sample documents will be reviewed with a “how to” audit surgical records.

You Will Learn:

• Introduction to the Audit Process
• Minor vs. Major Surgical Procedures
• The Global Surgical Package Concept Refresher
• Surgery 101…Access, Approach and Repair
• Assessing the Diagnosis Code(s) for Support and Medical Necessity
• Making Sense of the Results

–Evaluating and Rating the Surgical or Medical Document

–Reporting the Findings

–Interactive Auditing Session

Auditing whether done internally or externally takes a different skill set than what we are currently using as coders. Focus must be shifted from the code assignment to taking a global look at the documentation for all relevent information to maintain compliance in our practices. With the focus on OIG, RAC, HEAT and Payer audits you need to learn what goes into a successful audit to help protect your practice for the future.

CEU approved for all CPCs and the following specialties: CPMA, CGSC

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About The Presenter

Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, is the Vice President of Business and Member Development for the American Academy of Professional Coders (AAPC). A seasoned coder and coding educator, she previously served the AAPC as director of local chapter relations and as a member of the organization’s National Advisory Board. She is a certified coder and PMCC coding instructor, and speaks frequently at coding conferences. She is the owner of Coding and Reimbursement Experts, and teaches coding at the Venango campus of Clarion University. Prior to her employment with the AAPC, Ms. Buckholtz was administrator for Wolf Creek Medical Associates, managing a five location multi-specialty practice and was business manager at an otolaryngology practice.

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