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Wiki Standards for Auditing a Chart

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em2177

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Would anyone happen to know what are the standards when auditing a chart. I am in charge of compiling a list since I am going to be training a non coder on what to look for when auditing a chart. Can anyone help me with creating a cheat sheet on what to look for. This will be pretty basic since the person I am training will only be scanning the documents needed for the auditing.
Thanks for your help!
 
Not sure what you mean by simple standards, but when I audit, I start by looking for the basics - does the documentation support the service billed? also things like dates and signatures, and of course medical necessity.
 
There's LOTS of things you can look for in an audit:

E/M level selection
Modifier usage/omissions
Codes not age appropriate (i.e. well visits)
Well visits and E/M on same day
E/M and procedures on same day
Proper selection of E/M category (i.e. new patient vs. consult)
Are the records legible?
Any abbreviations should be easily recognized
Is the providers name and credentials present?
Incident to (medicare)
Can you identify who has made entries on the files? (i.e. ma, rn, md)
Is the patient's name, date of birth, and date of service on every chart note?
If a consult, is the referring MD info provided?
Does the recorded history and physical findings support the problem/diagnosis?
Are the problems/diagnoses recorded in the chart?
Have important health issues be left unmanaged?
Do xrays and labs support the problem/diagnosis?
Are abnormal findings properly followed up?
Are the names, dosages, quantities of prescribed meds recorded?
If there's an injection, does the note state the route, name, dosage and who gave injection?
If there's an injection, was the administration fee coded?
Are copies of consults from consulting physicians present?
Is there a complete history from initial visit?
If you use a superbill, you can audit that and make sure all codes are up to date and current.


Does that help?
 
auditing

It sounds like you are talking about auditing chart notes for E/M codes. (I audit all types of bills on a daily basis in my job.)

First, if your charts do not have the following components, you probably won't meet the requirements for the codes being billed: patient history, physical exam, and medical decision making. You must have all 3 for a new patient. You need 2 out of 3 for an established patient. If one of those required components is missing, you won't pass an audit.

patient history component:
Your patient history needs to include the history of the present illness, a review of body/organ systems and depending upon your level being billed, past/family/social history. A detailed history is going to include one, and a comprehensive is going to require 2 of the 3 (past/family/social)

exam component:
physical exams are obvious, so I don't need to go into much detail here.

medical decision making:
this includes the diagnosis, ordering tests/labs/radiology, etc, and/or a treatment plan.

The auditing tool sounds like it will be useful. I do use a levelling sheet at work. I have seen similar ones that also work. I have been auditing E/M codes for the past 3 years and after a certain amount of time, you get a feel for what is necessary...what to look for. It's not unusual to discover that one or more components are missing after I get the bill for processing.
 
I have a great form that I use when auditing, email me your email and I will send it as an attachment.

Jamie
 
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