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“Chart auditing should be performed quarterly at every medical practice ”
We understand the importance of effective medical chart transcription and how developing a practical audit program can impact your practice.

Medical Chart Auditing

When a letter from your carrier arrives telling you that you are going to be audited, will you be ready?
Physicianís offices are busy places, and often it takes everything you and your staff has just to get through the day seeing patients. Keeping track of records for errors and omissions may be a burdensome task and sometimes even impossible. While errors and omissions are not uncommon they may be costing your office more than you realize.

What Can You Do?

What can you do? Auditing medical charts is the first step and a critical part of any successful medical office operation. Although chart auditing may seem intimidating for many physicians, there are many positive aspects of chart auditing including increased revenue, treatment efficacy research, and peace of mind in the event of third party audits. New attention from the OIG, RACs, and other third-party auditors makes this built-in practice self-check more important than ever.

HealthCare Management Solutions offers concurrent and retrospective audits for a charge based payer population. These audits can be performed remotely from our office. Our professional coders are members of the American Academy of Professional Coders, AAPC. HealthCare Management Solutions has also partnered with AAPC and may also provide AAPC certified audits. We can prepare an off-site audit of approximately 10-15 patient charts to ensure compliance with Medicare (CMS) guidelines and to establish proper billing and documentation procedures to protect you and your practice from a Medicare audit. It is important to make sure all of your records are in order in the event of an audit.

AAPC Certified Audits

AAPC has been the authority in training and credentialing physician coders for decades. No one knows and understands coding regulations and documentation requirements better. So when AAPC validates and certifies the findings and recommendations of every audit, you are assured a level of accuracy that only comes from working with AAPC. Coding and billing requirements are complex, and policies and regulations can vary by region and carrier. That is why we use only the best auditors in the industry. Utilizing our vast network of medical auditing professionals, we provide expertise in every specialty.

Compliance Assurance

We can also assess your reimbursement and account receivable balances and current billing practices, whether itís currently being done in house or with another billing company. Our goal is to keep you within compliance, while providing you with the maximum amount of fee income. Improved coding and auditing guidelines can also improve the relationship between physicians, their patients, and third party payers.

Total Quality Improvement System

An essential key to long-term practice success is adapting a Total Quality Improvement system used by professional auditors. Below are 10 easy steps for a successful practice:

  • Have a proactive and knowledgeable stance when it comes to your office records.
  • Communicate confidently with physicians and staff about proper chart documentation
  • Find under or over documentation in your charts that can create improper code selection.
  • Implement controls to help prevent coding errors.
  • Ensure that appropriate levels of service are identified and billed.
  • Learn how to audit based on coding facts and potentially uncover missed revenue.
  • Learn the proper steps for choosing appropriate levels of history, exam, and medical decision-making.
  • Get the chart audit forms to implement your internal audit program
  • Receive a thorough E/M documentation guidelines review.
  • Make chart auditing an essential component of your practice compliance plan.

Although these 10 tips are very helpful to get you started in maintaining and verifying your charts, we encourage you to allow HealthCare Management Solutions to provide your practice with more extensive training in chart auditing that will prove invaluable to your office operations. Our professionals will not only give you the tools that you need to complete thorough chart audits to address your specific Total Quality Improvement goals, but will also walk you through the process so that the staff understands the various and sometimes complex aspects of medical coding.

Our company has been using HealthCare Management Solutions for over a year. We are a successful multi specialty practice that has recently incorporated neurology, intensivist, psychiatry, urology, general surgery, and neurosurgery. These additions to our practice occurred without an increase in denials and days in A/R.
Jill Hall - Director of Business Services @ Northeast Georgia Physicians Group
Copyright © 2018 - Healthcare Management Solutions, LLC.
HealthCare Management Solutions, LLC.
4452 Congressional Drive
Jacksonville, FL 32246