The Audit Process

Why This Topic Matters

Audit programs affect compliance, documentation quality, coding accuracy, and revenue integrity. Understanding the overall audit workflow helps organizations choose an appropriate review approach and communicate findings effectively.

Article Sections

1. Preparing for the Audit

   Introduces the planning phase of a healthcare audit and the main questions used to define scope and approach. Covers the broad categories of audit focus and how the review is organized.

2. Extent of the Audit

   Describes the major audit scope categories used in healthcare operations. Explains the kinds of areas that may be reviewed within each audit focus.

3. Type of Audit

   Reviews the primary audit timing options used in healthcare review processes. Distinguishes between different audit strategies at a high level.

4. Choosing Between Random or Targeted Audits

   Covers how organizations may decide between broader sampling and focus-area review. Discusses general considerations that influence audit selection.

5. Determining the Scope: How Many Records to Audit?

   Addresses planning factors that influence record volume for a review. Includes discussion of organizational size, risk areas, and sample representation.

6. Choosing the Records

   Explains the record-selection phase of audit planning and the role of statistical sampling tools. Mentions software-supported methods used to help structure the sample.

7. Performing the Audit

   Introduces the execution phase of the audit process and the types of resources used during review. Focuses on the general tools and reference materials that support audit work.

8. National Correct Coding Initiative (NCCI) Edits

   Covers a federally related edit system used during claim review and how it fits into auditing workflows. Discusses the types of edit checks considered in the review process.

9. Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs), and Payor Policies

   Summarizes coverage guidance sources used in audit review. Includes Medicare-related coverage guidance and payer-specific policy considerations.

10. CPT, ICD-10-CM, and HCPCS II Books

    Describes the use of coding references during audit work and the importance of matching review materials to the service year. Also addresses how policy references are used alongside coding resources.

11. Coding and Billing Auditing Software

    Discusses the use of software tools to support audit workflows and reporting. Covers the general role of automation, analytics, and trend tracking.

12. The Audit Report

    Introduces the reporting stage of the audit process. Focuses on how findings are organized and communicated after the review is complete.

13. Crafting the Audit Report

    Describes the broad components commonly included in an audit report. Emphasizes summary, findings, and individualized reporting structure.

14. Presenting Audit Results to Physicians/APPs

    Covers communication considerations for sharing audit findings with clinicians and other providers. Discusses the general approach to feedback, education, and follow-up.

15. Conclusion

    Wraps up the article with the overall purpose of auditing and the value of constructive communication. Reinforces the collaborative role of audit results in improvement efforts.