Wiki Auditing -documentation requirement

[fami]

Hello All,

I need to find a source to mention what is requirement to audit a medical record - should it be a complete medical record or a super bill and MD order would be enough?

I disagreed with a advice that a new consulting company told us - there is no need for complete progress note to audit.

Please help!

SP

 

[kevbshields]

The health record (as source document) and perhaps the claims that were submitted to payers and any EOBs or RAs that relate to those claims--that is primarily what is used in an audit.

I'm not sure I understand the logic of this consulting company--perhaps they are new to coding audits or have a "green-horn" consulting on your project (?). Maybe go with another company though. Doesn't sound like these folks are going to do justice for the money they're charging you.

Good luck.

 

[cheermom68]

audit

I agree with Kevin. It is impossible to audit without the complete medical record. The superbill is not even a permanent part of the record. I would question any outside company who audits without the complete record.

LeeAnn

 

[twizzle]

Auditing. Documentation requirements

I would want to audit this audit company because they have a very strange approach to compliance/documentation requirements.

 

[DeeCPC]

The National Alliance of Medical Accreditation Services (NAMAS) and AAPC study guide for the Certified Professional Auditor Medical Auditor (CPMA) certification discuss what is required to audit the medical record.