What is medical auditing?

Quality health care is based on accurate and complete clinical documentation in the medical record. The best way to improve your clinical documentation and the livelihood of your health care organization is through medical record audits. They are necessary to determine areas that require improvements and corrections.

The goals of an audit are to provide efficient and better delivery of care and to improve the financial health of your medical provider. Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by physician documentation. Once areas of weakness are revealed through an audit, you can present the audit findings and identify opportunities for training in your health care organization.

What Is Medical Auditing and Why Perform One?

Medical auditing entails conducting internal or external reviews of coding accuracy, policies, and procedures to ensure you are running an efficient and hopefully liability-free operation.

There are many reasons to perform medical audits:

  • To determine outliers before large payers find them in their claims software and request an internal audit be done.
  • To protect against fraudulent claims and billing activity
  • To reveal whether there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
  • To help identify and correct problem areas before insurance or government payers challenge inappropriate coding
  • To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door
  • To remedy undercoding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures
  • To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
  • To stop the use of outdated or incorrect codes for procedures
  • To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness

Become an Auditor

To help medical professional maximize coding and billing efficiency and quality of care through auditing, AAPC has the Certified Professional Medical Auditor (CPMA®) credential. The CPMA® will help you determine key areas of weakness in your practice, so you can provide detailed recommendations to resolve them. As a medical auditor, you’ll focus on practice areas such as:

  • Compliance and regulatory guidelines
  • Coding concepts
  • Scope and statistical sampling methodologies
  • Medical record auditing skills and abstraction ability
  • Quality assurance and risk analysis
  • Communication of results and findings
  • Medical records supporting services rendered

For the CPMA® exam, the majority of the questions are presented in multiple choice format covering auditing theory, legal and regulatory issues, National Correct Coding Initiative (NCCI), RAC audits, statistical sampling, coding concepts, modifiers, etc. Each test taker needs to audit approximately 20 health care cases.

For more information on how to take your coding career to the next level and prove your worth as a CPMA®, click here.

Hire an External Auditor

AAPC also has an audit services division, AAPC Client Services, which provides full-service health care compliance and corporate integrity audits for outpatient practices, health plans, health care attorneys, and government regulators to ensure supported medical necessity, correct coding, and compliance with regulatory issues. Get more information on how AAPC Client Services can fulfill your auditing needs.

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