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Medical auditing is a review of a patient medical record to ensure documentation meets compliance requirements for medical necessity and coding accuracy.

The industry allows the use of either guideline. Both guidelines have pros and cons, it depends upon the nature of the presenting problem in which a patient is being seen by a healthcare provider. The best way to determine what is most advantageous is to compare the two versions.

For a baseline compliance audit, 10-15 patient charts is an industry-standard. For a focused audit, the sampling should increase to 10% of the eligible charts.

Risk Adjustment is a healthcare payment model that reimburses health plans that disproportionately attract higher-risk populations (patients) by transferring funds from lower-risk populations to higher risk populations. Both the insurance plans and physicians share in the risk for caring for patients, therefore both can participate in Risk Adjustment.

A score of 90% or higher is the most common threshold used to set the standard of performance by which organizations can measure and monitor coding accuracy.