Medical Chart Auditing Services

Chart Auditing

Why should you be auditing your charts and how often?  These are questions that we can answer for you.  With the ever-growing problem of the misconceptions about documentation, chart auditing has become extremely vital to protecting a practice’s revenue.  No provider wants an insurance to come back and recoup payments due to not meeting documentation or medical necessity guidelines.  Having an effective auditing program is not only essential for practice revenue, but it can decrease your compliance risks and increase your peace of mind, which is the purpose of our audits.

Graceful Beginnings Healthcare Consulting Services, LLC provides personalized, cost-effective, and high-quality auditing services to all healthcare professionals.  The coding and billing professionals are Certified Professional Coders and have experience in documentation and compliance.  We conduct audits that are tailored to our client’s pinpoint areas of vulnerability in billing and/or compliance.  Chart reviews are typically performed remotely, but we will work with you to identify the most appropriate method to obtain the records selected for review.

Our Chart Auditing service includes, but is not limited to, the extensive review of the quality and completeness of chart documentation, the appropriateness of the procedure and diagnostic code selections, as well as the verification that all appropriate services were billed.

We perform a coding and documentation review of  randomly selected patient encounters per provider. The selection size is contingent on the type of specialty of the practice, the type of services provided, total number of providers, the patient volume, and the number of practice locations. We perform, monthly, quarterly, and annual audits. You select what type of audit you would like performed and we take it from there.

  • Documentation Review and Coding Selections:
    1. Does the documentation address the chief complaint
    2. Is the medical necessity of the service supported
    3. Does the documentation support the procedure and the diagnosis
    4. Are all services billed supported by the documentation
    5. Are consultations and referrals documented
    6. Are laboratory, DME, and other orders documented
    7. Are prescriptions documented
    8. Are the next steps for the patient documented
    9. Does the documentation support the level of E&M selected
    10. Are all of the diagnosis codes selected correct and supported in the documentation
    11. Are the procedure codes selected, correct and supported
    12. Are appropriate modifiers used

In addition to evaluating the overall effectiveness of your billing process we also examine the following key areas:

  • Verify services documented are billed
  • Determine appropriateness of bundling or unbundling of services
  • Encounter form/Superbill review
  • E/M and procedure code modifiers
  • Evaluating the link between CPT codes and ICD-9 codes on CMS-1500 claim forms
  • Comparing code choices to codes placed on the CMS-1500 claim forms by data entry personnel

There are five types of chart auditing services that we offer:

  • Coding review only, prospective, or retrospective
  • Coding and documentation review, prospective or retrospective audit
  • Focused Audit
  • Corporate Integrity Agreement (CIA) Audit
  • Quality Assurance

Here is a description of what each audit entails:

  • Prospective Audit – Our expert coding team will take a look at your claims, pre-submission, to ensure that your claims are accurate, compliant, and denial-proof.
  • Retrospective Audit – Our coding experts will review your claims and documentation history to identify areas for improvement in your coding, billing, and documentation practices.
  • Focused Audit – Our coding team will review your claims history in search of specific areas, identified by your organization, as trouble areas.
  • Corporate Integrity Agreement (CIA) – Has a payer identified problems in your coding practices? Our AHIMA certified professional coders will investigate your medical records and     help you correct the identified problems.
  • Quality Assurance Audit – Our coding team will review your medical records for completeness from continuity of care to office notes, labs notations, etc.

The chart auditing coding summary shall include the DOS, CPT code (with library description), and modifier.  There will also be a brief comment on the accuracy of each entry and any discrepancies, errors, and/or comments under the comment section as well as follow-up education. Our chart auditing services are for paper charts, EMR, and EHR.

Our customized package includes:

  • Chart Audits
  • Detailed Audit report along with recommendations and cross references to coding guidelines
  • Consultative Session (includes provider training and education (One-on-One or Group by phone)
  • Coding Assessment
  • Follow up audit (if necessary)

Graceful Beginnings Healthcare Consulting Services, LLC is now helping providers with Meaningful Use Audits.  If your practice has been selected for a meaningful use audit contact us today!

Contact Us Today by phone at (877)353-8819 or email us at for more information about our coding services or to schedule your chart review!

Graceful Beginnings Healthcare Consulting Services | Ph: (520)230-5820 | Fax: (877)358-6369 | P.O. Box 2047 | Sierra Vista, AZ 85636