About HCM105A — Medical Record Auditing, Part 1
This course is Part 1 of 2 and covers a comprehensive range of topics related to medical record auditing, compliance in medical practices, regulatory guidance, documentation basics, the medical record, clinical documentation improvement, and auditing fundamentals. Students will explore the role of the medical record auditor, including the purpose of medical record auditing, the auditor's responsibilities and qualifications, and the importance of certification.
Students will focus on compliance in the medical practice, covering areas such as the patient medical record, fraud and abuse laws, carrier audits, the significance of a compliance plan, the benefits of a compliance plan, recommended compliance plan elements, the National Correct Coding Initiative, coding based on standards of medical or surgical practice, and medically unlikely edits.
The course then delves into regulatory guidance, discussing topics such as the scrutiny of coding and billing practices, external audit triggers, medical record chart audits, recovery audits, government audit programs, the Medicare appeals process, responding to postpayment audits and refund requests, audit prevention, performing internal audits, and the corporate integrity agreement.
Students will learn about documentation basics, including the history and purpose of medical record documentation, the medical record as a legal document, progress notes, SOAP notes, operative reports, documentation guidelines, and the impact of documentation on coding. The course explores the medical record itself, covering topics such as its definition, the role of the medical record administrator, medical record accountability, privacy, and release of information, components of the medical record, advance beneficiary notices, record retention, and HIPAA privacy regulations.
The course focuses on clinical documentation improvement, discussing documentation standards, the importance of clinical documentation improvement, establishing a CDI program in the medical office, and the role of the certified documentation improvement practitioner. Part 1 of Medical Record Auditing ends with an introduction to auditing fundamentals, including top coding and documentation errors, the importance of auditing and analyzing medical records, types of audits, an overview of the audit process, auditing and monitoring guidelines, audit analysis and reporting, and ongoing monitoring.
