Chart Audit & Documentation Advice

Chart audit and documentation is not a topic that interests many clinicians. Most commonly, chart audits are perceived as a very negative element of insurance company reviews that have the potential to result in claim recoupments and lost revenue. Every practice needs to have their charts reviewed on a regular basis to ensure that not only their documentation supports the levels of service that they have billed in the past, but also to ensure that they are not underbilling--that is, billing at levels lower than that which is supported by their documentation. Many times, providers are limited in the levels of service that they can bill because their systems or templates don't prompt them to record the right information. Minor tweaks in templates or EHRs can often significantly improve the documentation of services, which, in turn, can increase the level of service that can be supported by the documentation.

However, you don’t need a consultant to ride in and pronounce your coding good or bad or to charge you to tell you secrets. What you really need is a partner who can train your staff and give them the tools that you need in order to be able to ensure the highest possible quality of billing and coding. You can move forward confidently—knowing that your coding is the best it can be because of the support and training provided by RMACI.

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