decisionhealth Newsletters, Answer Books - 2011 Issue 4 (April)
Chart Audits / 12 tips for conducting chart audits
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Article Overview
This article explains what auditors and practice staff should look for when reviewing patient charts for documentation quality and compliance. It focuses on broad audit-readiness issues such as chart support for billed services, diagnosis consistency, test ordering and results, office interpretations, legibility, patient identifiers, and CMS signature expectations. It is aimed at physicians, coders, billing staff, and compliance-minded practice administrators.
Why This Topic Matters
Chart audits help practices identify documentation gaps before they become denial, recoupment, or compliance problems. Understanding the major areas of review can improve record integrity and reduce the risk that billed services cannot be supported during an audit.
What You Will Learn
- What types of documentation auditors commonly review in patient charts
- How chart content is compared against billed services and claim data
- Which record elements support tests, interpretations, and office workflow documentation
- Why signatures, legibility, and patient identifiers matter in audit review
- How Medicare signature guidance is referenced in chart audit context
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Practice managers
- Compliance staff
- Auditors
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