Documentation Audits

Codes billed must be supported by the documentation present in the medical charts. It is important to get a documentation audit to ensure that the documentation in the EHR is complete from the point of view of accuracy, compliance and defendable if questioned by the payer.

With our experience of dealing with denials across multiple payers in multiple states, our team can provide you with extensive feedback on how to improve small things that make your documentation of patient charts more robust and ready to face any cross-checking by the payers.

Here are the top 9 reasons why you should get a Documentation Audit done, as per American Academy of Professional Coders (AAPC):

  • To determine outliers before large payers find them in their claims software and request an internal audit be done.
  • To protect against fraudulent claims and billing activity
  • To reveal whether there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
  • To help identify and correct problem areas before insurance or government payers challenge inappropriate coding
  • To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door
  • To remedy under-coding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures
  • To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
  • To stop the use of outdated or incorrect codes for procedures
  • To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness