Focus Audit Results on the Documentation, Not the Encounter

by  Scott Kraft, CPC, CPMA
June 30th, 2017

As an auditor, your job is to assess the quality of the documentation created by the provider to determine whether it meets the requirements to bill the code assigned to the service. This task often set us up a potentially adversarial role with the provider, particularly when it comes to sharing the results of the audit.

One of the ways in which physicians challenge the results of the audit is to go after the credentials of the auditor. Most experienced auditors have heard some version of "You're not a physician", or the question, "Where did you go to medical school?".

Often, that tension comes from the way in which the audit results are presented to the physician. We know that the documentation is the sole written record of what took place during the encounter. "If it isn't documented, it isn't done", is something we've both learned and repeated over the years.

While that may be true for purposes of documentation and code selection, it often isn't true in practice. We know that physicians often inadvertently omit components of the actual encounter from the documentation. Maybe the severity of a chronic condition that the physician saw with the patient wasn't reflected in the documentation.

Perhaps some component of the plan for an assessed condition wasn't recorded by the physicians, who was already behind on the schedule for that day. Presented with the finding that the visit itself was insufficient to support the code will often rankle physicians, who interpret it as a personal criticism of the quality of the work.

Communication such as this matters - if the physician takes umbrage at how the results are presented and becomes less receptive to the message, then the ultimate goals of an audit- to mitigate risk and improve the overall documentation of the provider - are at risk of not being met.

Consider this - when discussing the results of the audit with the physician, make it clear that our work is not a commentary on the quality of the medical care provided or of the quality of the physician-patient interaction. Many of us can attest to the quality of care furnished by the physicians we work with each day.

It's just an assessment of the documentation - an opportunity to look for the best ways to ensure that the documentation captures everything that took place during the encounter, and to ensure that the codes assigned by the physician or the practice best match the appropriate codes for the service.

We all know that sometimes, the rules of documentation can be unfair. Forget to include social history for a new patient encounter with high medical decision making, and a 99205 suddenly can't be coded as higher than a 99203. Well, as auditors we know that - our physicians aren't always in the weeds on the rules of documentation.

They're as likely to react negatively and challenge how a patient so severely ill can warrant only a level three service - if told that the visit could only achieve a 99203, rather than being told that the coding rules require that the omission of family history limit the overall credited history to 99203.

It's unfair - I tell physicians that all the time. Then we work together to determine the best ways to ensure accurate coding of encounters and capture of all appropriate documentation. After all, that's why we audit.

Focus Audit Results on the Documentation, Not the Encounter. (2017, June 30). Find-A-Code Articles. Retrieved from

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