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Thread: Auditing -documentation requirement

  1. #1
    Join Date
    Apr 2007

    Default Auditing -documentation requirement

    AAPC: Back to School
    Hello All,

    I need to find a source to mention what is requirement to audit a medical record - should it be a complete medical record or a super bill and MD order would be enough?

    I disagreed with a advice that a new consulting company told us - there is no need for complete progress note to audit.

    Please help!


  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    The health record (as source document) and perhaps the claims that were submitted to payers and any EOBs or RAs that relate to those claims--that is primarily what is used in an audit.

    I'm not sure I understand the logic of this consulting company--perhaps they are new to coding audits or have a "green-horn" consulting on your project (?). Maybe go with another company though. Doesn't sound like these folks are going to do justice for the money they're charging you.

    Good luck.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3
    Join Date
    Apr 2007
    Evansville Indiana

    Default audit

    I agree with Kevin. It is impossible to audit without the complete medical record. The superbill is not even a permanent part of the record. I would question any outside company who audits without the complete record.


  4. #4
    Join Date
    Apr 2007
    Sarasota FL

    Default Auditing. Documentation requirements

    I would want to audit this audit company because they have a very strange approach to compliance/documentation requirements.

  5. #5


    The National Alliance of Medical Accreditation Services (NAMAS) and AAPC study guide for the Certified Professional Auditor Medical Auditor (CPMA) certification discuss what is required to audit the medical record.

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