Always indicate in your report the total # of samples reviewed, what type services are included in the sample selection and what the requirements are.
Example: As part of the compliance program's work plan I performed a billing, documentation and coding review. The review consisted of 10 samples relative to your services to monitor coding accuracy and teaching physician rules, with results summarized below.
Always start off with letting them know the results up front, example:
7 out of 10 samples were coded at the correct level.
In the report you can display your findings like this:
Inpatient consultations (99254):
Reminder:
Level 4 inpatient consultations require the documentation of:
- a comprehensive history (4 HPI elements, 10 (or more) ROS, all 3 PFSH) and
- a comprehensive exam (8 organ systems) and
- moderate MDM
2 of 3 samples reviewed; 99253 billing was supported for the following reasons:
- history level detailed; 10 (or more) ROS not documented
- physical exam detailed; 5-7 organ systems documented
This is an example for E/M services, hope it helps.
Maria Candia CPC, CPC-H, CPCO, CPMA, CEMC