How to successful audit guide.pdf - AAPC How to Perform a Successful Chart Audit 2010 AAPC 2480 South 3850 West Suite B Salt Lake City Utah 84120

How to successful audit guide.pdf - AAPC How to Perform a...

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AAPC 2480 South 3850 West, Suite B Salt Lake City, Utah 84120 800-626-CODE (2633), Fax 801-236-2258 AAPC How to Perform a Successful Chart Audit 2010
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i How to Perform a Successful Chart Audit Written by: Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, COBGC, CEMC, CDERC, CPCD, CCS-P
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Perform a Successful Chart Audit ii AAPC 1-800-626-CODE (2633) Disclaimer This course was current at the time it was published. Although every reasonable effort has been made to assure the accu- racy of the information within these pages, the ultimate responsibility lies with the readers to ensure they are using the codes correctly. The AAPC’s employees, agents, and staff make no representation, warranty, or guarantee that this com- pilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient health care organizations. Notices CPT® copyright 2009 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommenda- tion their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. All Rights Reserved. CPT ® is a registered trademark of the American Medical Association (AMA). CPC®, CPC-H®, CPC-P®, CIRCC® and CPMA TM are trademarks of the AAPC © 2010 AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah 84120 800-626-CODE (2633), Fax 801-236-2258, All rights reserved. ISBN 978-1-936095-33-9
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Perform a Successful Chart Audit iii Contents Introduction 1 What Is Medical Necessity and Why Does It Matter? 1 Medical Necessity and CMS 2 The Purpose of Auditing and Monitoring . 3 The Medical Record 3 Why Perform the Audit? . 4 Internal vs . External Audit 4 Top Billing and Coding Errors . 5 Top Evaluation and Management Coding Errors 7 Auditing Evaluation and Management Services 7 Which E/M Guidelines Should You Use? . 7 Auditing the Surgical Medical Record . 8 Global Surgery Package: What’s Included? 8 Medicare Surgical Guidelines . 8 Minor Surgical Procedures . 8 Major Surgical Procedures . 8 Correct Coding Initiative (CCI) 9 Unbundling . 9 Unbundling Prevention Tips . 9 Performing the Chart Audit 9 Audit Objectives 10 Revenue . 10 Evaluating for Compliance . 10 Beginning the Audit Process 11 How to Conduct a Chart Audit Step by Step 12 Step 1: Identify Audit Objectives . 12 Step 2: Sample Size 12 Step 3: Develop or Select an Audit Tool 13 Step 4: Perform the Audit 13 Step 5: Complete the Review Analysis and Summary Report . 14 Step 6: Meet With the Practitioner 14 Step 7: Make Recommendations for Improvement 14 Step 8: Provide Monitoring and Guidance . 14
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Perform a Successful Chart Audit iv AAPC 1-800-626-CODE (2633) Audit Tools 15 E/M Audit Form Example 16 Score: Physical Examination Component 17 Table of Risk . 18 The Audit Report . 20 Medical Record Chart Audit Summary Report . 21 Communicating Audit Results .
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