1. Define Audit Scope
- Focus Areas: Coding accuracy, documentation, compliance
- Sample Size: 5-10% of claims (stratified by provider/service)
- Timeframe: Monthly/quarterly reviews
2. Gather Documentation
✔ Patient records
✔ Charge sheets
✔ Payer policies
✔ Fee schedules
3. Verify Key Elements
- Coding: CPT®/ICD-10 accuracy
- Modifiers: Proper usage (e.g., -25, -59)
- Medical Necessity: Diagnosis supports procedure
- Charge Capture: All services billed
4. Check Compliance
✔ HIPAA adherence
✔ Payer-specific rules
✔ Anti-kickback/Stark Law
5. Analyze & Report Findings
- Calculate error rates
- Identify patterns (e.g., one provider undercoding)
- Recommend corrective actions
6. Implement Improvements
- Staff training
- Process adjustments
- Follow-up audits
Best Practices:
✔ Use audit templates
✔ Compare against industry benchmarks
✔ Document all findings
