NOV 11, 2022
How to Perform Internal Chart Audits in 10 Steps
REVISED NOV. 1, 2023
You know you should be conducting internal chart audits, but don’t know how and where to start? The steps in this article will help you initiate your audit and see you through the entire process from identifying audit targets to implementing a plan to prevent the discovered deficiencies.
- Identify Potential Audit Targets. You will most likely be audited based on your volume. Run a productivity report to identify the top exam visit codes, testing services, procedures, modifiers and surgeries you perform, and get started on those with the highest volume.
- Understand the Requirements. Who is the payer and where can you find their requirements? Start with your top 5 payers and locate their policies online or through payer representatives. The most recent Medicare local coverage determination documents and articles can be found at aao.org/lcds
- Create a Checklist. Develop a checklist that includes the payers’ documentation requirements. This is the only way to consistently maintain compliance.
- Determine the Sample Size.The most important thing is to start with one chart and go from there. Be flexible and prepare to audit more charts when deficiencies are found.
- Gather all Pertinent Documentation. Print out all the documentation as you would for an external audit. This will allow you to review your specific audit target requirements and the general audit requirements, including:
Perform the Audit. Use the checklist and set deadlines. When a deficiency is found, determine if it is an isolated event for one physician or date of service by auditing other physician’s chart notes or the same physician’s notes on different dates of service. Correct any coding errors and submit voluntary refunds to the payer as appropriate.
Analyze and Verify the Results. Create a simple results report and determine if additional charts should be audited. Identify any patterns, such as day of the week, time of day, location, work-up tech, scribe, physician or type of examination/procedure/surgery. Document and track all audits in your formal compliance plan.
Share the Results. Share the audit results with everyone involved in the documentation and coding and billing processes. The physician is ultimately responsible for all the documentation in the chart but the team of allied health technicians, scribes, coders and billers all contribute.
Create a Compliance Plan. Based on the findings, create a plan to help prevent the deficiencies. While creating the plan, ask for and take into consideration feedback from the entire team. Record the completion of ongoing education sessions in your compliance plan.
Implement the Plan. Once finalized, implement your plan by clearly communicating the needed changes and holding each other accountable by auditing the changes as you go and correcting mistakes as soon as possible. Remember: What we monitor, we improve.
- Date of service
- Patient identifiers on every page
- Physician signature
- Additional testing results
Resources for Audit Success