Medical Chart Audit Services
Medical coding accuracy is essential to your organization's revenue cycle and compliance efforts. A medical chart audit reviews your documentation and coding practices to ensure compliance, accuracy, and proper reimbursement. DoctorsManagement offers comprehensive chart audit, medical billing audit, and coding review services to help you improve documentation and ensure revenue stability.
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What Is a Medical Chart Audit?
A medical chart audit is a comprehensive review of your practice's coding and documentation practices to ensure accuracy, compliance, and optimal reimbursement.
A chart audit — also known as a medical billing audit or coding audit — analyzes coding and documentation practices to ensure accuracy, reliability and effectiveness. A medical chart audit examines documentation with a two-prong approach:
Reimbursement Analysis
Documentation is analyzed to the payor reimbursement policies to ensure accuracy and create a sustained revenue cycle.
Compliance Assessment
Medical coding and documentation must also be scrutinized to coding and E&M billing rules and guidelines to assess the accuracy of your compliance. Medical billing audits can reveal areas of risk and educate providers and staff about recent changes to rules and regulations.
Correct coding is the pathway to accurate reimbursement and maintained compliance. For this reason, an effective medical chart audit program will ensure the accuracy of both revenue and compliance.
Comprehensive Medical Chart Audit and Coding Review Services
DoctorsManagement is committed to the success of your medical chart audit and review process. Our expert auditing team performs accuracy reviews for medical coding and documentation that simulate an actual carrier audit, allowing you to address deficiencies and lower risk accurately. We customize our chart audit services to address your needs or project.
Information Collection
Medical chart auditors on our team will advise on sample size and structure in an effort to provide a comprehensive review of all service lines provided per physician and non-physician-qualified provider.
Data Analysis
We will analyze the coded service as compared to the documentation support to identify areas of proficiency and deficiency within compliance and also with respect to reimbursement. These reports provide claim-level feedback and are a standard deliverable we provide with all our medical chart audits.
Extensive Report of Findings
Our medical chart auditors can provide more specified coding audit results and recommendations report. This report includes the data analysis findings and recommendations as an overview with site and sourced published rules and guidelines. We recommend this report for chart audits that include deficient precision scores for compliance purposes.
Feedback Training Session
We recommend feedback training sessions based on the chart audit and compliance review outcomes. Audit reviews that meet proficiency standards can be addressed collectively in group sessions. Audits found having deficient precision standards allow for designated one-on-one training to ensure understanding and acknowledgment of ongoing modifications necessary for compliance and accuracy in reimbursement.
Our Medical Chart Audit Process
Every medical chart audit we conduct follows a proven methodology designed to deliver actionable insights and measurable improvements to your coding accuracy and compliance.
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Claims Selection & Sampling Statistically valid sample selection based on service lines, providers, and risk areas
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Documentation Review Line-by-line analysis of medical records against submitted codes
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Compliance Verification Assessment against current CMS, OIG, and payer-specific guidelines
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Revenue Impact Analysis Identification of under-coding, over-coding, and missed charges
Week 1-2: Preparation
Initial consultation, scope definition, and sample selection for your medical chart audit
Week 2-4: Active Review
Certified auditors conduct thorough chart audit review of selected claims and documentation
Week 4-5: Analysis
Data compilation, trend identification, and findings synthesis
Week 5-6: Reporting
Comprehensive audit report delivery with actionable recommendations
Week 6+: Training
Customized education sessions based on chart audit findings
The Importance of Medical Chart Audits
Medical coding accuracy can affect several aspects of your practice, including your compliance risk and revenue stream. A medical chart audit can assist with improving coding quality and documentation support, enabling you to lower risk and ensure accuracy of revenue.
Medical chart audit reviews can help your organization:
- Identify current documentation, coding, and reimbursement policies and guidelines
- Locate services not reported and untapped areas of reimbursement
- Correct misuse of electronic medical records within documentation
Maintained Compliance
Medical chart audits can address coding compliance concerns within your documentation and coding processes. They enable you to stay updated on new laws and regulations and may help you identify areas of risk for improvement to mitigate claim recoupments.
Saved Time and Money
Accurately coded and documented claims can lead to fewer rejections and denials. Chart audits help you quickly identify and correct such concerns and issues so more cases can be paid fully and on time while eliminating duplicative work caused by denials.
Improved Internal Processes
Medical chart audits can uncover improvement opportunities to include efficiencies in processes and reimbursement. Ongoing annual chart audit reviews ensure your organization is following proper internal processes and procedures that result in quality medical coding.
When Should You Conduct a Medical Chart Audit?
Regular medical chart audits are essential, but certain situations call for immediate review. Here are key indicators that your practice needs a chart audit.
High Denial Rates
If your practice is experiencing denial rates above 5-10%, a medical chart audit can identify the root causes and corrective actions needed.
New Providers or Staff
When adding new physicians or billing staff, a medical chart audit establishes baseline accuracy and identifies training needs.
Payer Audit Notification
When notified of an upcoming payer audit, conduct your own chart audit first to identify and address potential issues proactively.
EHR System Changes
After implementing a new EHR or making significant system changes, a medical chart audit ensures coding integrity is maintained.
Revenue Fluctuations
Unexplained changes in revenue or reimbursement patterns warrant a chart audit to identify underlying coding issues.
Annual Review
Best practice recommends at least annual medical chart audits to maintain compliance and identify continuous improvement opportunities.
Why Choose Our Team for Medical Chart Audits?
As a full-service consultancy firm located in the U.S. with all U.S.-based team members, DoctorsManagement has the chart auditing expertise and resources to help a variety of organizations, including solo practices, group practices, multi-specialty clinics, hospitals and large integrated health systems.
Our highly skilled and experienced medical chart auditors can assist you in identifying and correcting deficiencies within your coding and documentation processes. We have specialized team members to provide support in all specialties and sub-specialty for adult and pediatric medicine.
We have access to proprietary technology to assess your critical risk areas and recommend adjustments that can help you mitigate risk, reduce coding errors and address your revenue streams.
Certified Auditors
AAPC & AHIMA certified
U.S.-Based Team
100% domestic staff
All Specialties
Adult & pediatric coverage
Proprietary Tech
Advanced risk assessment
Cathy Garguilo
Compliance Expert
Paul Spencer
Audit Specialist
Scott Kraft
Compliance ExpertFrequently Asked Questions About Medical Chart Audits
Get answers to common questions about the medical chart audit process and how it can benefit your practice.
How often should we conduct a medical chart audit?
Best practice recommends conducting a comprehensive medical chart audit at least annually. However, practices with high claim volumes, multiple providers, or recent compliance concerns may benefit from quarterly or semi-annual chart audits to ensure ongoing accuracy and compliance.
What is the typical sample size for a medical chart audit?
Sample sizes vary based on practice size and audit objectives, but typically range from 10-30 records per provider. Our auditors will advise on statistically valid sample sizes to ensure comprehensive coverage of all service lines and risk areas.
How long does a medical chart audit take?
A typical medical chart audit takes 4-6 weeks from initiation to final report delivery. This includes sample selection, documentation review, analysis, report preparation, and presentation of findings. Complex or large-scale chart audits may require additional time.
What areas does a medical chart audit examine?
A comprehensive medical chart audit examines E/M coding accuracy, procedure coding, modifier usage, documentation support, medical necessity, compliance with payer policies, and revenue optimization opportunities including under-coded services.
Will a medical chart audit help with payer audits?
Yes, proactive medical chart audits help identify and correct coding issues before payer audits occur. They also demonstrate due diligence and a commitment to compliance, which can be valuable if your practice faces an external audit.
What credentials should medical chart auditors have?
Qualified medical chart auditors should hold certifications such as CPC, CCS, CPMA, or CEMC from recognized organizations like AAPC or AHIMA. All DoctorsManagement auditors maintain current certifications and ongoing education requirements.
Strengthen Your Team's Coding & Documentation Skills
A chart audit is just the beginning. Our customized team training programs help your providers and staff build the skills they need to code accurately, document thoroughly, and stay compliant with ever-changing regulations. From provider documentation training to coding and billing education, we offer on-site and remote sessions led by CPC- and CPMA-certified experts.
Explore Team Training ServicesRequest a Medical Chart Audit
Ready to improve your coding accuracy and compliance? Contact our team to discuss your medical chart audit needs and receive a customized proposal.
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DoctorsManagement does not work with patients. We offer support to medical practices.
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