Results 1 to 5 of 5

Chart Audits

  1. Default Chart Audits
    Medical Coding Books
    I am looking for any info on doing chart audits. I have been recently promoted to a new position in my company and have not done chart auditing before. Any information would greatly appreciated.

  2. #2
    DoctorsManagement has a chart auditing workshop that has recently gotten underway. The number is 1-800-635-4040 Ask for Donna Hurley. I have seen parts of this and it appears to be very good.

  3. #3
    I actually took the course through Doctors Management for Certified Medical Auditor a few weeks ago and passed the exam! Shannon Smith was the instructor and she's wonderful!

  4. Unhappy New Coder lost in abstracting NEED HELP!!!
    Hi Forum! I am a new certified coder, new to the forum and have been coding for only 4 months...I need guidance!!!!

    I have been working in a pediatric office doing chart auditing and abstracting, also high volume charge entry, I never can seem to get a straight answer from my billing department.

    1. When a pt is seen for a well check and the doctor comes across a diagnosis example: Otitis media, strep throat anything contradictory to a wellness exam, does the doctor have to include this in the well check? I have been told that it is to the doctors discretion whether or not they want to bill the diagosis with the well check. I know that if the doctor prescribes a medication for the problem and spent time talking about it, depending on the type of insurance we can bill an ov with a 25 modifier. But what if nothing was done to help the problem? I hope this makes sense....And as a coder if they do not add it to the encounter/superbill is it my responsibility to ask whether they want to include it or not?

    2. I have a doctor in my office that when a pt is seen for pharyngitis/strep with strep screen done, he marks on the encounter pharyngitis/strep w/out wanting to bill for the strep screen, but bills for a detailed visit? In the chart he does note that a rapid strep screen was done....All the other docs in my office bill for an intermediate visit when this exact visit is seen. Is this unethical? As a new coder to the industry can I get in trouble for this? I am still learning on how to distinguish the 4 types of visits (Brief, Intermediate, Detailed and High Complexity)

    3. To bill an OV, we use the SOAP format in our office, as a coder do I only pay attention to what is marked in the Assessment portion of the chart to abstract the diagnosis to bill the visit?

    There are so other questions I need answers on but I will start off with these first, any insight would be greatly appreciated!!!

    Thank you,

    Frustrated Coder....

  5. #5
    I was wondering.
    I too have recently been asked to perform some chart audits on the Drs in my office. This is not something I have done previously but I do want to do a good job for them. Did you come across any good information on the best way to perform the audits or a good guideline to follow. I do not have time or money right now to take a class on it, but will definitely look into that in the future.

    Thank you in advance for any help you can offer on this,

Similar Threads

  1. Chart audits
    By nc_coder in forum Family Practice
    Replies: 1
    Last Post: 06-27-2013, 02:52 PM
  2. Chart Audits
    By trishs in forum Auditing General Discussion
    Replies: 1
    Last Post: 06-07-2013, 11:38 AM
  3. Chart audits
    By hfiessinger in forum Family Practice
    Replies: 0
    Last Post: 09-13-2011, 12:17 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.