General Surgery Coding Alert - 2013 Issue 3
Auditing: Follow This 10-Point Checklist for Successful Self-Audits
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Article Overview
This article explains how a medical practice can approach internal self-audits to review documentation, billing records, and claims for consistency and compliance. It is aimed at coders, auditors, and practice administrators who want a general checklist for evaluating whether records support billed services and reported information before an outside review occurs. The piece highlights broad audit questions across service level support, coding accuracy, consult documentation, signatures, legibility, and patient record completeness.
Why This Topic Matters
Self-audits can help practices identify documentation gaps and coding or compliance concerns early, before an external auditor reviews the records. That makes the article relevant for organizations trying to strengthen billing integrity and preparedness.
What You Will Learn
- How self-audits help compare billing records, claims, and medical records
- What broad documentation and compliance areas to review during an internal audit
- Which record-quality elements are commonly checked in a chart review
- Why consult documentation, signatures, legibility, and patient identifiers matter in an audit context
Who Should Read This
- Medical coders
- Certified professional coders
- Compliance staff
- Practice administrators
- Physician office auditors
- Revenue cycle teams
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