Checklist for Chart Audits

June 17, 2010

Select 10 charts per provider

  • Reflect a full range of E/M Codes
  • New, Established & Consults
  • Review Notes & Encounter form
  • Group practices summary to assess risk & make appropriate documentation changes
  • Results presented one-on-one
  • Schedule regular follow up audits
  • E/M Accuracy (use template to audit History, PE and MDM levels documented)
  • Procedural Coding accuracy
  • Utilize Daily Schedule and Monthly OR log to ensure all charges are captured
  • Daily Hospital encounter tracking
  • Review Op Notes for modifiers, bundled/unbundled codes and services
  • Review Op Notes for correct submission of Extensive or unlisted services
  • Consult request/report
  • Modifier usage
  • ICD-9 accuracy
  • Date of service compared to billing date
  • Legibility
  • Insurance authorization
  • Diagnosis consistent with findings
  • Consistent with Chief Complaint
  • Consistent treatment plan/diagnosis
  • Name/number on each page
  • Author identification and signature
  • Allergies documented

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