Documentation & Coding Audit Review

Documentation & Coding Audit Review

Audits & Reviews

Just as the accuracy of your coding determines the amount of your reimbursements, the documentation behind that coding either protects your revenue or leaves you vulnerable to repayment demands.

In 2021, we experienced the most dynamic coding changes in healthcare with the adaptation of patients over paperwork in the new guidelines for office and clinic based services with 2021 Documentation Guidelines. January of 2023, these guidelines expand into other areas of E&M services such as inpatient, emergency department, home-based care, nursing facility services, and a few other variations. 2021 Documentation Guidelines rely not on checklists, templates, and macros, but on the complexity of the care rendered to the patient. Some questions you might consider:

Have you sampled your providers documentation?

Do they understand how to level their encounters?

Have you started training affected providers for 2023 implementation?

Whether you’re a physician office, group practice, multi-specialty clinic or hospital, our coding and auditing team members are highly skilled at helping your organization identify and correct deficiencies and vulnerabilities so that your documentation supports optimal reimbursement and reduces your exposed risk.

A coding and documentation audit and review from DoctorsManagement will:

  • Identify areas of performance proficiency and deficiency for each provider and also note positive performance
  • Identify opportunities for improvement to templates and documentation that has not been updated for 2021 Documentation Guidelines.
  • Provide all services reviewed and audited for both documentation content for guideline consideration, as well as medical necessity, evaluation of billing inconsistency with incident-to, split-shared, and teaching physician guidelines
  • Uncover audit risk for COVID-19 and TeleHealth claims
  • Teach your providers how to avoid pitfalls when using shortcuts such as EMR templates
  • Train your staff to communicate in a way that improve future results

What to do next…

Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
Read more: What can you expect from a coding and compliance review?

Here’s why thousands of providers trust DoctorsManagement to help improve their coding and documentation.

Quality of coders and auditors. Our US-based auditors receive ongoing training and support from our education division, NAMAS (National Alliance of Medical Auditing Specialists). All team members possess over 15 years of experience and hold both the Certified Professional Coder (CPC®) as well as the Certified Professional Medical Auditor (CPMA®) credential.

Proprietary risk-assessment technology – our auditing team uses ComplianceRiskAnalyzer (CRA)®, a sophisticated analytics solution that assesses critical risk areas. It enables our auditors to precisely select encounters that pose the greatest risk of triggering an audit so that they can be reviewed and the risk can be mitigated.

Synergy – DoctorsManagement is a full-service healthcare consultancy firm. The many departments within our firm work together to help clients rise above the complexities faced by today’s healthcare professionals. As a result, you receive quality solutions from a team of individuals who are current on every aspect of the business of medicine.

Call Us (800) 635-4040