Medical chart audits are a necessary function in the healthcare administrative process. A medical coding audit provides detailed information about the overall operations of the medical practice including coding, billing, documentation, reimbursement and compliance. Our auditing team is multi-distinguished holding active credentials as Certified Professional Medical Auditor (CPMA), Certified Medical Auditing Professional (CMAP), Certified Professional Compliance Officer (CPCO), Certified Healthcare Compliance Officer (CHCP), and Certified Professional Coder (CPC). Our Senior Auditor leads the team with over 20 years of experience.
Most Requested Audits
Evaluation & Management
Behavioral Health Services
Audit Sample Size
Most requested- 10 Charts/p
2) 20 Charts / Provider
3) 25 Charts / Provider
4) 15 Charts / Provider
5) 5 Charts / Provider
You determine how many charts we audit!
Where we Audit
Onsite at your location
Hybrid Audit- a combination of onsite and remote
What we Audit
1) Determine the type of audit needed. Our team can assist by recommending an audit once we understand your objections and you as a client.
2) Determine the number of charts to be audited.
3) Determine a deadline for the audit
4) Complete audit agreements, HIPAA agreements, and establish primary contact
5) Establish chart access
6) Receive the audit report with findings and recommendations
7) Set up an optional conference call to discuss findings, recommendations, and next steps
8) Organize optional training, if recommended
Medical chart audits are an essential aspect of the healthcare industry. These audits involve a thorough review of patient medical records, modifier usage, quality of care, documentation, proper reimbursement and compliance. The goal of medical chart audits is to ensure that healthcare providers are providing high-quality care and following established protocols.
Performing chart audits has numerous benefits for both healthcare providers and patients. One of the most significant benefits is improved patient safety. By reviewing medical records, healthcare providers can identify potential errors or omissions in patient care, such as medication errors or missed follow-up. This allows for timely intervention and correction of such errors, improving patient safety and reducing the risk of adverse outcomes.
Medical chart audits also help to improve the quality of care provided by healthcare providers. By reviewing patient records, healthcare providers can identify areas where they may need additional training or education. They can also identify patterns or trends in patient care that may indicate a need for changes in treatment protocols or policies.
In addition, chart audits are an essential tool for healthcare providers to ensure compliance with regulatory and accreditation standards. Audits can identify areas where the practice may be falling short of these standards, allowing for timely correction and improvement. Audits provides the opportunity to identify missed revenue, identify areas of risk, challenge coding practices, improve documentation and to mitigate potential risk areas currently on the Office of Inspector General's (OIG) Work Plan.