Medical Chart Auditing
Medical Chart Auditing
Medical chart auditing is the process of reviewing medical records to ensure accuracy, completeness, and compliance with coding and billing regulations. Candidates must understand the audit process: selecting a sample of records, reviewing documentation against codes billed, identifying discrepancies, and providing feedback and education. Audits can be internal or external, and they may focus on specific areas such as evaluation and management (E/M) services, surgical procedures, or documentation to support medical necessity.
A key trap in exam questions is the difference between a compliance audit and a coding audit: a compliance audit focuses on adherence to regulations and policies, while a coding audit specifically checks the accuracy of code assignment. Another trap is the use of the audit tool: auditors must use standardized tools and check for elements such as history, examination, and medical decision-making for E/M codes, or the components of a surgical procedure.
Auditors must also be aware of the 2021 E/M guideline changes, which shifted to medical decision-making or time as the basis for code selection for office visits. Documentation must support the level of service billed. The audit process should include a random sample, a defined sample size (often 10% or a minimum number), and a clear scoring methodology.
Worked example: An auditor reviews 10 records for established patient office visits. For one record, the provider billed a 99214 but documented only two stable chronic illnesses and prescribed medication, which supports a 99213 under the 2021 guidelines. The auditor notes the discrepancy and recommends education on medical decision-making. Rule of thumb: always use the current year's E/M guidelines and ensure documentation meets the level of service billed.