Auditing
An audit may be necessary when it is realized payment was not received when the documentation to approve payment is not available or is inadequate. For example, an appeal for an unpaid office visit is rejected due to lack of supporting documentation while a patient is in a postoperative period with the correct modifier applied on the bill. The problem may be that a significantly separate evaluation was completed but not documented.
It is important when performing audits to document all the findings of incompleteness and of inaccuracy in the coding and billing. A report needs to be prepared summarizing the findings and those need to be conveyed to all staff. Many times not including all the staff in discussions of how to improve documentation leads to gaps in the medical record. Team effort and education create completeness.
Providing health care is not only based on excellent patient care but is also based on accurate and complete clinical documentation in the medical record. EHR documentation has made this easier; however, it has also made us lazy to some extent and has given us a need to be critiqued. The best way to maintain your clinical documentation at a high level is through medical record audits. They are necessary to determine areas that require improvement and ensure completeness.
The goals of an audit are to assess and provide efficient feedback to maintain financial health of the medical provider. Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by provider documentation. Once areas of concern are identified during the audit, these areas can be addressed with training.
Why healthcare records need to have audits performed:
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To assess correct use of ICD-10-CM
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To assure electronic health record (EHR) meaningful use compliance
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To identify possible sources of error that could generate an insurance audit
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To evaluate compliance with billing guidelines
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To identify possible sources of Stark law violations, MAC and RAC audit items, anti-kick back and anti-trust noncompliance
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To locate failures in local coverage determination (LCD) and national coverage determination (NCD) compliance which will lead to denials
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To ensure reimbursement is maximized
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To ensure current coding and billing policies and procedures are effective
An audit may be necessary when it is realized payment was not received when the documentation to approve payment is not available or is inadequate. For example, an appeal for an unpaid office visit is rejected due to lack of supporting documentation while a patient is in a postoperative period with the correct modifier applied on the bill. The problem may be that a significantly separate evaluation was completed but not documented.
It is important when performing audits to document all the findings of incompleteness and of inaccuracy in the coding and billing. A report needs to be prepared summarizing the findings and those need to be conveyed to all staff. Many times not including all the staff in discussions of how to improve documentation leads to gaps in the medical record. Team effort and education create completeness.
Compliance and Advising
During the audit we review medical records for completeness, compliance with coding standards, review for possible missed charges, and correct diagnosis. With this information, we prepare the report of audit. Most importantly, we review with the office staff and providers the findings and make recommendations for improvement. There needs to be policies and procedures put in place to help implement areas of correction. We go beyond this and train key staff on the information obtained and make suggestions for future interventions and education.