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Medical Record Audits
Monitoring coding and documentation through external medical record audits is an effective
part of your compliance program. Compliance audits also help prepare and protect your
organization from increasing scrutiny by governmental agencies.
BSA Healthcare has performed external chart audits for billing and coding
companies and physician groups around the country. Audits are performed pre- or post-claim
submission and focus on (1) assessing the potential loss of revenue resulting from poor
documentation and/or conservative or incorrect code choice (2) evaluating any compliance
issues that may arise as they relate to code choice methodologies.
External chart audits may include a review of one or all of the following:
- Evaluation and management (E/M) and procedure code choices
- ICD-9 diagnostic code choices
- E/M and procedure code modifiers
- Evaluating the link between CPT codes and ICD-9 codes on CMS-1500 claim forms
- Comparing code choices to codes placed on the CMS-1500 claim forms by data entry personnel
BSA Healthcare Services
EMERGENCY MEDICINE & PHYSICIAN SPECIALTY SERVICES
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