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

Why This Topic Matters

Self-audits can help practices identify documentation or coding issues before an external audit. The article is relevant to coding, billing, and compliance teams looking for a structured way to review records and strengthen internal processes.

Article Sections

1. What it means

   Introduces the purpose of a self-audit and the general types of records and documentation involved. It frames the article as a practical guide for internal review in a medical practice.

2. 1. Involve the whole staff

   Discusses communicating the audit process to practice staff and setting the tone for an internal review. The section emphasizes team awareness and participation.

3. 2. Select the charts

   Covers choosing a sample of records for review and the overall scope of chart selection. It presents a general approach to deciding which records to audit.

4. 3. Examine documentation

   Focuses on comparing documentation with the codes assigned to services and identifying documentation support issues. It references the use of diagnosis and procedure coding review as part of the audit process.

5. 4. Pay special attention to difficult services

   Addresses services that can be harder to review during an audit, including evaluation and management documentation considerations. It also discusses time documentation as part of the review process.

6. Time-based pitfall

   Highlights concerns related to time-based documentation and the importance of recording timing information clearly. The section explains why documentation detail matters when supporting the use of time in service review.

7. 5. Use a score sheet

   Describes using audit worksheets or score sheets to document findings and organize the review. It notes that audit tools can help standardize internal documentation of results.

8. Tip

   Provides a short reminder about keeping the audit tool and review process aligned with documentation requirements. It emphasizes retaining a record of the internal audit.

9. 6. Educate your staff about your findings

   Explains sharing audit results with practitioners, coders, and billers after the review is complete. The section focuses on using findings to support staff education and process improvement.