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Medical Record Chart Audit

  1. #1
    Location
    San Gabriel Valley,CA
    Posts
    311
    Default Medical Record Chart Audit
    Medical Coding Books
    Can anyone tell me what a medical record chart audit consist of? One of the Doctor's office that I code for is being audited by a health plan and they are wondering what too look for in order to be prepared. Any information would be greatly appreciated.
    Thanks,
    Elizabeth M., CCS, CPC, ICD-10 CM/PCS
    Multi Specialty Coder/Compliance Auditor/ICD-10 Educator

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default
    These are some of the top coding/documenation errors:

    -Documentation does not support the level of service
    -Chief complaint is missing
    -Assessment is not always clearly documented
    -Documentation is not signed
    -Tests ordered are not listed in the documentation but are billed
    -Documentation of meds are not always clear
    -Dx is not referenced correctly or incorrect linkage
    -Missing documentation/forms missing in chart
    -Lost dictation
    -Encounter forms are not available
    -Documentation is not complete or hard to read
    -Missing modifiers
    -Improper use of CPT codes
    -Medical Necessity

    These are some errors that auditors look for. Anyone else?

  3. #3
    Location
    San Gabriel Valley,CA
    Posts
    311
    Default
    Thanks Rebecca for the very useful information!
    Elizabeth M., CCS, CPC, ICD-10 CM/PCS
    Multi Specialty Coder/Compliance Auditor/ICD-10 Educator

  4. Default
    Is it an audit or a medical record review? I work for a health plan that does medical record reviews. We are looking for HCC's to submit to Medicare. A review is nothing to sweat, we are just trying to improve benefits for our members.

    Andrea CPC-A

  5. #5
    Location
    San Gabriel Valley,CA
    Posts
    311
    Default
    This was actually for an audit not a medical record chart review.
    Thanks,
    Elizabeth M., CCS, CPC, ICD-10 CM/PCS
    Multi Specialty Coder/Compliance Auditor/ICD-10 Educator

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