Surgical Chart Audits: Cutting Into the Documentation
- Dates: On-demand
- Location: Virtual (online)
- Presentation Length:
- Author: Brenda Chidester Palmer CPC, CPCI, CASCC, CEMC
AHIMA Approved ICD-10 trainer
Enhance your knowledge and defend your practice by developing the skills necessary to accurately review the surgical note from the selection of notes to the feedback to the provider. Office based procedures and major surgery each need to contain specific information to validate billing for the codes submitted on a CMS-1500. Documentation of these types of services also need to contain information for peer-review or quality audits.
This workshop will address the aspects of auditing the surgical record. Focus on auditing the surgical note from a coding perspective will be our primary goal but we will also will discuss the audits from a peer-review or QA perspective.
We begin with the basic of what we need to audit each type of surgical record including open fractures, closed treatment of fractures, laparoscopic and other procedures. Then get into actual documentation and perform audits. Once the audit is complete, reports of audit findings need to be generated and presented to the appropriate sources.
- Key surgical terms
- Review of anatomic areas
- Anatomy of the surgical notes
- How to pull out the key elements of the surgical note
- How to create reports for feedback
- Key tips on presenting findings to physicians and leadership
About The Author
Brenda Chidester Palmer CPC, CPCI, CASCC, CEMC
Brenda has 19 years of coding and billing experience. She is the principal of Palmer Coding Consultants. Palmer provides auditing and education services to physician offices. She is the former coding compliance manager for a Kelsey-Seybold Clinic, a large multi-specialty group practice in Houston, Texas. Palmer is an approved PMCC instructor, former AAPC workshop presenter, past president of the Tyler, Texas,local chapter, and a former member of the AAPC National Advisory Board.
*On demand and virtual workshops are for single person use only and may not be rebroadcast,
retransmitted, shared or disseminated. A computer with a high speed Internet connection
and speakers (or headphones) is recommended to connect to the event.