# Auditing -documentation requirement



## fami (Jun 18, 2011)

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!

SP


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## kevbshields (Jun 21, 2011)

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.


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## cheermom68 (Jun 21, 2011)

*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.  

LeeAnn


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## twizzle (Jun 21, 2011)

*Auditing. Documentation requirements*

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


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## DeeCPC (Jun 21, 2011)

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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