Expert Audit Protection, Increased Reimbursement

Wouldn’t it be great if you had the ability to maintain the highest level of compliance and also dramatically increase your reimbursement rates? Prosperis Consulting can provide a thorough review of your coding, notation and charting processes. We can identify areas of risk for your practice and even provide training for documentation techniques that could improve your workflow

Services

The specific details of the chart audit may vary depending on the purpose and scope of the audit, but typically involve the following steps:

1. Selection of Charts: This can be done randomly, based on specific criteria (e.g., high-risk cases), or as a representative sample.
   
   
2. Review of Documentation: Examination of the medical records, including progress notes, history and physicals, consultation reports, lab results, diagnostic reports, medication records, treatment plans, and other relevant documents.
   
   
3. Compliance Assessment: Ensures that the documentation in the medical records complies with legal and regulatory requirements, such as coding and documentation guidelines, privacy and security standards, and healthcare regulations like HIPAA (Health Insurance Portability and Accountability Act.
   
   
4. Accuracy of Diagnosis and Procedure Coding: Verification of the accuracy of diagnosis coding (using ICD codes) and procedure coding (using CPT or HCPCS codes) in the medical records.
   
   
5. Documentation Quality Assessment: Evaluation of the quality of clinical documentation, including the clarity, specificity, and completeness of the information recorded.
   
   
6. Compliance with Standards of Care: Assessment of whether the documented treatment plans and interventions align with established protocols, guidelines, or standards of care.
   
   
7. Identification of Deficiencies: Deficiencies, errors, or areas of improvement are identified and documented. This may include missing or incomplete information, insufficient documentation to support the diagnoses or procedures, inaccurate coding, or non-compliance with documentation standards.
   
   
8. Recommendations and Reporting: Suggestions for enhancing documentation practices, improving coding accuracy, ensuring compliance, or addressing specific deficiencies identified during the audit.

What You Can Expect from Chart Audits

Once the audit is performed, you’ll be given a detailed report and consultation to review the findings. We go beyond a simple error report and actually recommend corrective actions. We can also provide training to implement solutions.