Wiki Medical Record Chart Audit

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em2177

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Can anyone tell me what a medical record chart audit consist of? One of the Doctor's office that I code for is being audited by a health plan and they are wondering what too look for in order to be prepared. Any information would be greatly appreciated.
Thanks,
 
These are some of the top coding/documenation errors:

-Documentation does not support the level of service
-Chief complaint is missing
-Assessment is not always clearly documented
-Documentation is not signed
-Tests ordered are not listed in the documentation but are billed
-Documentation of meds are not always clear
-Dx is not referenced correctly or incorrect linkage
-Missing documentation/forms missing in chart
-Lost dictation
-Encounter forms are not available
-Documentation is not complete or hard to read
-Missing modifiers
-Improper use of CPT codes
-Medical Necessity

These are some errors that auditors look for. Anyone else?
 
Is it an audit or a medical record review? I work for a health plan that does medical record reviews. We are looking for HCC's to submit to Medicare. A review is nothing to sweat, we are just trying to improve benefits for our members.

Andrea CPC-A
 
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