preview

Perspective Audit Worksheet

Better Essays
Open Document

Discuss and define the two types of medical record audits: Retrospective and Prospective. List the steps a medical manager must follow to properly audit an E&M service.
There are two types of audits in the medical field: Retrospective audit is an audit performed on services that have already been billed to the carrier (Andress, 2009). It also determines whether overpayments on claims have been made to a certain physician practice. Should it identify overpayments made, the practice must issue a refund to the insurance carrier. It is generally based on review of records of discharged patients. Prospective audit is an audit performed on services that have not yet been billed, and is designed to reduce liability (Andress, 2009). It is based …show more content…

2) Look at the patient encounter form for that date of service.
3) By reviewing the documentation, determine the category of service provided (e.g., new office patient, subsequent hospital visit, consultation).
4) Using the documentation guidelines, carefully review the history portion of the visit.
a. Is there a chief complaint or reason for the visit?
b. Is there a history of present illness? How many elements of the history of present illness are documented?
c. Is there a review of systems? How many systems?
d. Is there a past, family, and/or social history?
5) Carefully review the examination portion of the note. Using the guidelines listed previously, what level of examination is documented?
6) Carefully review the medical decision-making portion of the note.
a. How many diagnoses or management options are there?
b. What quantity of data were …show more content…

9) Compare the reviewer's level and category with the level and category checked on the patient encounter form. Does it match?
10) Next, verify the medical necessity for the visit and any ancillary services that were performed.
a. Is the medical necessity for that level supported?
b. Is the medical necessity documented for any additional services performed during that visit?
11) Do the diagnosis codes checked on the patient encounter form match the codes listed in the medical record for that date of service?
a. Are they correct? Are they in the same order? Are any diagnosis codes missing?
b. Are any diagnosis codes listed that are not supported in the medical record?
12) Were any services performed that were not captured for billing?
13) Did the provider of the service (e.g., physician, nurse practitioner, physician assistant) sign the note?
14) Does the note contain the same date of service as the patient encounter form?
15) Is the patient's name or identifying number on each page (front and back) of the medical record?
16) Is the service part of a teaching physician service?
a. Did this service involve a

Get Access
Related
Get Access