Updated and revised, the fourth edition of Medical Record Auditor offers an in-depth discussion of how the medical record is structured and how to review medical record documentation to determine level of service. In addition to reviewing the documentation and coding guidelines used today, including evaluation and management (E/M) guidelines, this resource provides chart-auditing fundamentals, case studies, and other helpful examples to guide and enhance your understanding.
Designed to help navigate the important topic of record auditing, this book assists physician practices in maintaining compliance with the government, insurance carriers, and other agencies that review medical records.
Tools are provided to aid in the proper audit of medical records, as well as instruction on analyzing and reporting results of an audit. Chapter exercises are included to test the reader's comprehension of the material.
New to this edition:
- NEW – Cases, chapters, direction for electronic health record (EHR) auditing
- NEW – Chapter on Clinical Documentation Improvement
- NEW – Downloadable audit forms
- NEW – Downloadable Audit Analysis Form and Summary Report
- NEW – Eighteen evaluation and management E/M case studies for the office setting
- NEW – Surgery audit cases
- NEW – Other services audit cases (anesthesiology, radiology, PT and E/M other)