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Thread: Operative Report Audit

  1. #1
    Join Date
    Apr 2007
    Casa Grande & Phoenix

    Default Operative Report Audit

    AAPC: Back to School
    Is there a specific auditing form for procedures/op reports? I have a very helpful E/M audit form but nothing for op reports. Any help is appreciated!!
    Tara Johnson, CPC

  2. #2
    Join Date
    Apr 2007
    Swainsboro/Statesboro, GA

    Default Procedure note auditing form

    I've never seen anything like this, but it's possible to develope your own auditing tools. I did this for E&M auditing, but I have also done this for other auditing projects. I find that I work better when I read the regulations on the subject I am auditing, and develope my audit tool from those CMS regulations.

    In your question of auditing procedure notes, it could be difficult to create individual procedure audit sheets, but if you are auditing some of the same procedures, it may be worth it to take the time to do so.

    You could also develope a "master" audit tool for all procedures (things that would be required no matter what the procedure), such as patient name, pre and post op diagnosis, physician name, procedure name, date, justification for the procedure, complications, outcome, physician signature, etc. Your employer may also have certain requirements that must be met, such as physician signature within a certain time frame.

    There are also some requirements in the Codes of Participation. These are usually included in your hospital policies, but it is always a good idea to verify this.

    Good luck!
    Freda Brinson, CPC, CPC-H, CEMC
    2014 President AAPC Swainsboro, GA Chapter
    Past President - 2012, 2008; Past Vice President - 2013, Past Education Officer - 2009 of Savannah, GA Chapter
    Past Member AAPCCA Board of Directors (2009-2012)

  3. #3
    Join Date
    Apr 2007
    Casa Grande & Phoenix

    Default Op Report Audit

    Thanks so much for your help!!
    Tara Johnson, CPC

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