Preparing for a coding audit: A guide for physicians

You’ve received a request for medical records from a payer, who is going to conduct an audit on your claims. Your Electronic Health Record (EHR) system is excellent, the notes are voluminous, your providers are well-versed at coding. If anything, you under code! You provide excellent care for your patients and achieve great outcomes. No one has ever given you any trouble before. An EHR system is supposed to make your life easier. It provides accurate, up-to-date information about the patient. Its purpose is to facilitate coordinated access and information sharing among physicians. It helps providers more efficiently diagnose patients, reduces errors, provides safer care, facilitates quality. And, by the way, it does a bang-up job of capturing essential billing elements. Pop in the right template, maybe tweak it a little, and you’re good to go.

Medigy Insights

While useful for providing accurate and up-to-date patient information, EHR can also lead to inaccuracies in the medical record if information is carried forward without being properly edited. This can result in allegations of "cloning" notes, where a provider is accused of copying and pasting information from prior visits, which can lead to denied claims and financial penalties. The passage also highlights the importance of ensuring that the medical record is accurate and free of conflicting information, as even small inaccuracies can lead auditors to question the integrity of the entire record. Overall, the passage suggests that it is important for providers to be aware of the potential risks and challenges associated with medical audits, and to take steps to ensure the accuracy and integrity of the medical record to avoid potential issues.