DCBA

Medical Record Audit

Our medical record audit services include inpatient as well as outpatient assessments which enable you to get an accurate idea of where you stand regarding accuracy and compliance. The inpatient Audit Services can also provide valuable information to help you gauge progress and effectiveness of your Clinical Documentation Improvement initiatives. In addition to an exit conference, DCBA's HIM consultant and/or physician consultant present educational information for the staff to enhance coding and clinical knowledge.

• Coding Accuracy – review of each medical record to evaluate accuracy of coding professionals in assignment of correct ICD-9-CM diagnostic and procedure codes
• Compliance – review of diagnostic and procedural codes for compliance with official coding guidelines and DRG assignment; assessment of indications for observation services as well as hospital acquired conditions will be included
• Severity - review of documentation to determine coders' abilities to capture true severity of patient illness
• Potential – physician review of records to evaluate the ability of the medical staff to provide the documentation required for most accurate and specific code assignment that portrays the patients' severity of illness and risk of mortality
• Estimate of ROI – projection of the potential benefit of coding professional education and physician documentation training on all of the above

• Emergency Room – evaluation of professional and facility E&M coding as well as procedural coding for accuracy and determination of educational opportunities for improvement, both in coder needs as well as physician documentation needs
• Outpatient procedures – evaluation of CPT coding accuracy, incorporating modifier analysis, charge master issues and billing processes as well as physician documentation to assure compliance
• Surgical Center – evaluation of CPT coding accuracy, incorporating modifier analysis, hard coding from automated processes, charge master issues and billing processes as well as physician documentation to assure compliance
• Diagnostics – evaluation of ICD-9-CM code assignments for patients sent to the facility for laboratory studies or radiologic studies
• Clinic services – audit of documentation and coding for E&M, procedures, modifiers and integration of charge description master