SELF-AUDIT: 6 Steps Help You Perform a Successful Self-Audit

Why This Topic Matters

Self-audits help practices identify documentation and billing issues internally before they are found in an external review. This makes the topic relevant to compliance, reimbursement accuracy, and staff education.

Article Sections

1. Overview

   Introduces the purpose of a self-audit and the general areas a practice should review. It frames the article around internal compliance and preparation.

2. 1. Involve the whole staff

   Discusses the importance of communicating the audit process to everyone in the practice and setting expectations for participation.

3. 2. Select the charts

   Covers general chart-selection considerations for record review during a self-audit.

4. 3. Examine documentation

   Describes reviewing documentation against assigned diagnosis and procedure coding at a high level.

5. 4. Pay special attention to difficult services

   Addresses more complex record types and evaluation and management services, including time-based documentation concerns.

6. Time-based pitfall

   Expands on documentation considerations related to time-based evaluation and management reporting and related audit scrutiny.

7. 5. Use a score sheet

   Covers the use of audit tools or worksheets to organize findings and support internal documentation of the review.

8. 6. Educate your staff about your findings

   Explains sharing audit results with practitioners, coders, and billers to address problem areas and improve future compliance.