Independent Coding and Documentation Audits

It is important to realize that a medical record audit will focus on procedural and diagnosis code selection as determined by the physician documentation. Here are three important reasons to do regular Coding and Documentation Audits:

  1. Coding must match the services for the claims paid by the insurance company. Therefore, the OIG Compliance requires regular independent Audits.
  2. Coding and Documentation Audits can identify problems. An audit will objectively analyze and detect holes in the coding process or uncover deficiencies.
  3. Coding and Documentation Audits focus on the documentation and code training providers need to improve their coding habits.

These independent audits help you find ways to enhance clinical efficiency and can help protect the financial position of your medical practice.

An independent Coding and Documentation Audits can:

  • Protect against fraud. Coding must match the services for the claims paid by the insurance company.
  • Find variances due to incorrect coding or incomplete documentation
  • Identify and correct the coding and documentation problems before you are challenged by insurance or government payers.
  • Ultimately find new opportunities for reimbursement.
  • Correct providers’ use of outdated or incorrect codes.

Contact us for more information.