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.
Inpatient Medical Record Audit
The inpatient records assessment includes determining the accuracy and completeness of medical staff documentation, accuracy in identification of diagnosis and procedural ICD-9-CM codes and appropriateness in assignment of DRGs. The audit will reveal compliance issues related to physician documentation, coder accuracy and DRG assignment including an evaluation of technical and clinical knowledge. The data is presented in written report and spreadsheet format including charts and graphs to provide a quick and easy visual representation of the findings of the audit. The audit also will show opportunity for education and corrective action to improve performance. Further, the analysis will demonstrate financial aspects of the audit and annual impact is projected.
The inpatient audit will reveal:
- 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
Outpatient Medical Record Audit
Like the inpatient records assessment, the outpatient records assessment will gauge the accuracy and completeness of physician documentation. The outpatient records assessment also will identify medical necessity, as well as accuracy of identification of diagnostic and procedural codes.
DCBA provides analysis of ability of physicians to accurately reflect the procedures performed so correct CPT codes can be assigned and APC calculated. The outpatient audit will demonstrate coder accuracy in ICD-9-CM diagnosis codes, CPT codes, modifiers, CDM support and production of an accurate and compliant bill.
The outpatient audit will review:
- 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
Medical record audits often reveal the need for a clinical documentation improvement program
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