A key factor in compliance auditing is selection of charts for review. Ideally, charts are selected randomly (eg, every third evaluation and management service reported by Dr X during the selected period, up to 10 records). The individual who provided a service should not also audit the documentation and coding.
The auditor should
Auditors who are not clinicians should not attempt to audit for medical necessity other than that outlined in payer policy (eg, diagnoses required to support a service per health plan policy). Concerns about the medical necessity of a service must be addressed by a physician or other qualified health care professional who is qualified to apply clinical judgment to the medical necessity of services.
The audit findings should be first reviewed by the compliance officer or other party responsible for coding compliance and the practice administrator to determine any necessary corrective actions. Auditors should be accessible to...