Making a CPT Audit Checklist

An audit checklist allows for a systematic examination of compliance and quality at your medical practice. An extensive audit can assess a wide variety of areas such as documentation accuracy, coding accuracy, medical necessity substantiation, compliance, etc.

These aspects of managing a healthcare facility are all essential, and payers will expect you to provide evidence of them.

1. Scope of the Audit
An auditor should establish clear audit objectives, scope, and criteria to meet audit standards that they are assessing your organization against. All parties involved should agree upon and document this scope prior to starting their audits.

Internal audit leaders must be realistic about the resources at their disposal and the number of areas they can cover within an allotted timeframe. This will enable them to plan an efficient audit that addresses all key risks. They should ensure there are enough staff available for reviewing patient charts and billing statements in a timely manner; when selecting audit scope criteria they should also take into account any impacts from contractors or freelance workers with access to customer or company data – contractors or freelance workers could have different viewpoints as they have access to customer or company data that needs audited.

2. Prepare for the Audit
Regular medical coding audits are an integral component of operating an efficient healthcare organization. Audits allow healthcare organizations to identify areas of concern, increase educational opportunities and drive decisions within their system – however many organizations struggle with how best to prepare for and react after completion of such an audit.

Begin your audit by determining its scope. This should involve gathering data about clinical staff, providers, payers and billing and coding staff patterns as well as reviewing reports for risk areas or trends and reviewing CPT code usage by billing and coding staff.

Make sure that all paperwork is organized and complete, such as medical records, physician notes, lab results and examination rooms/waiting areas are clean. Furthermore, ensure all staff members understand the significance of upcoming audit and its importance – this will allow them to be better prepared and confident throughout its completion process.

3. Conduct the Audit
An audit can detect issues like extra payments and generous reimbursements that can compromise profitability in your practice. Conducting regular healthcare coding audits will allow you to detect these mistakes early, protecting profitability for years. A comprehensive medical coding audit checklist should cover patient information verification, documentation accuracy, CPT code accuracy, medical necessity substantiation and compliance measures.

Conduct your medical coding audit during a time when staff isn’t overburdened to avoid defensiveness about results and hindering improvement efforts. Also make sure you clearly communicate its purpose.

You should ensure you have an outstanding bill/charge ticket, claim form, billing record and chart organization as well as specialty forms like history forms, problem lists and medication sheets in place to review medical records effectively. In addition, reports should be run to compare physician services with those provided by peers to identify trends or risk areas.

4. Report on the Audit
After an audit is complete, a final report should be delivered to your company. This report should include a summary page, auditor’s name, the checklist items that did not conform with standards/expectations and suggested actions for rectifying them as well as possible solutions.

An independent medical coding audit is a thorough assessment of the quality and compliance of holistic practices’ coding procedures. Professional auditors take a systematic, structured approach to finding errors before they interfere with reimbursement.

An audit should begin with an initial “baseline” audit that evaluates various E/M services, office visits and procedures performed within your practice. This initial assessment provides a snapshot of your overall coding accuracy and compliance and acts as the starting point for more targeted audits to enhance quality coding practices. You should set an ongoing audit schedule to monitor results. A carefully prepared coding audit can provide invaluable assistance in optimizing Telehealth coders while assuring maximum reimbursements for your practice.