Q&A: Chart audit focus areas
Q: What topics should routine chart audits focus on?
A: Chart audits should be conducted on a regular basis to ensure that documen- tation is complete and accurate and that codes and charges are appropriately assigned. Chart audits should include the following four actions:
- Audit medical records against charges and claims to make corrections and improvements in charge capture, coding accuracy, billing, medical necessity, or documentation
- Audit patient charts and medical records to evaluate adequacy of clini- cal documentation, compliance, reasons for treatments, billed services/ items, coding, payments, operations, or completeness of bill
- Review medical records for accuracy and billing compliance
- Review hospital (or other healthcare facility) department medical record documentation for improvement opportunities as part of a scheduled periodic review process
For more information, see the CHRI Exam Study Guide.