Wiki Chart Audits


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I am looking for any info on doing chart audits. I have been recently promoted to a new position in my company and have not done chart auditing before. Any information would greatly appreciated.
DoctorsManagement has a chart auditing workshop that has recently gotten underway. The number is 1-800-635-4040 Ask for Donna Hurley. I have seen parts of this and it appears to be very good.
I actually took the course through Doctors Management for Certified Medical Auditor a few weeks ago and passed the exam! Shannon Smith was the instructor and she's wonderful!:)
New Coder lost in abstracting NEED HELP!!!

Hi Forum! I am a new certified coder, new to the forum and have been coding for only 4 months...I need guidance!!!!

I have been working in a pediatric office doing chart auditing and abstracting, also high volume charge entry, I never can seem to get a straight answer from my billing department.

1. When a pt is seen for a well check and the doctor comes across a diagnosis example: Otitis media, strep throat anything contradictory to a wellness exam, does the doctor have to include this in the well check? I have been told that it is to the doctors discretion whether or not they want to bill the diagosis with the well check. I know that if the doctor prescribes a medication for the problem and spent time talking about it, depending on the type of insurance we can bill an ov with a 25 modifier. But what if nothing was done to help the problem? I hope this makes sense....And as a coder if they do not add it to the encounter/superbill is it my responsibility to ask whether they want to include it or not?

2. I have a doctor in my office that when a pt is seen for pharyngitis/strep with strep screen done, he marks on the encounter pharyngitis/strep w/out wanting to bill for the strep screen, but bills for a detailed visit? In the chart he does note that a rapid strep screen was done....All the other docs in my office bill for an intermediate visit when this exact visit is seen. Is this unethical? As a new coder to the industry can I get in trouble for this? I am still learning on how to distinguish the 4 types of visits (Brief, Intermediate, Detailed and High Complexity)

3. To bill an OV, we use the SOAP format in our office, as a coder do I only pay attention to what is marked in the Assessment portion of the chart to abstract the diagnosis to bill the visit?

There are so other questions I need answers on but I will start off with these first, any insight would be greatly appreciated!!!

Thank you,

Frustrated Coder....
I was wondering.
I too have recently been asked to perform some chart audits on the Drs in my office. This is not something I have done previously but I do want to do a good job for them. Did you come across any good information on the best way to perform the audits or a good guideline to follow. I do not have time or money right now to take a class on it, but will definitely look into that in the future.

Thank you in advance for any help you can offer on this,