1. Internal Chart Audit Program

2. Overview
“A joint effort between the health care provider and the clinic staff is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

3. Reason For Audit Improvement of patient care (improved documentation)
Assess performance against standards (CMS, MGMA)
Ensure appropriate payment
Recover lost revenue through unbilled services
Identify areas of risk and meet compliance standards

4. Standards Evaluation & Service Management Guidelines
CMS 1995 Documentation Guidelines
CMS 1997 Documentation Guidelines
Medicare E/M Distribution 2008 or latest available data
Individual payer guidelines as necessary

5. Prep & Plan Quarterly audit Audit Schedule Advance Notification
Office E/M codes – retrospective & concurrent
12 random office medical records per provider
New patient
Established patient
Consults
Audit Schedule
Advance Notification
Letter to clinic manager to notify of upcoming audit
Request for medical records and scanned documents as necessary – 2 weeks

6. Actual Audit Audit Tool Patient chart components to be reviewed
Progress note
Orders for lab/x-rays, etc.
Results for lab/x-rays, etc
Other documents as needed
Fee ticket used for posting charges
Code Review
CPT code level of service and over/under coding)
Diagnosis code(s) assigned according to ICD-9-CM guidelines
Documentation
All services, supplies, & diagnoses reported
Is clear, legible, signed and dated by provider and/or nurse
Codes (for procedures, labs, & supplies appropriate and valid for DOS)
Findings requiring immediate attention reported to director/manager

7. Audit Report & Education
1 hour meeting with Clinic
Provider, group, office manager/director, nurse
Report findings of audit
Provide supporting guidelines from appropriate resources
1995/1997 guidelines
ICD-9-CM / CPT guidelines
Copies of report to:
Provider/Group
Manager/Director
CEO/COO

8. Reports Reports kept to identify: Monthly summary Quarterly summary
Refunds
Payments received on re-billed services
All results from audits
Monthly summary
Audit activity & results presented at managers meeting
Quarterly summary
Presented to ABC Executive Committee/Board

9. When will this start? First audit will start the week of January 1st
Questions!!