About HCM105B — Medical Record Auditing, Part 2
This course is Part 2 of 2, covering various aspects of auditing evaluation and management (E/M) services, office medical records, E/M audit case studies in both office and hospital settings, surgical medical records, and auditing diagnostic radiology and physical therapy services. Students will work on auditing evaluation and management services, covering topics such as key components and contributory factors, selecting a level of E/M service, documentation guidelines, medical record documentation importance, medical necessity and diagnosis coding for physician services, error rate testing program, 1995 vs. 1997 documentation guidelines, visits dominated by counseling and/or coordination of care, consultation guidelines, reporting consultations for CMS, nursing visit code reporting, preventive medicine services, preventive services by CMS, hospital observation services, discharge services, prolonged physician services, case management services, physician standby services, care plan oversight, critical care services, neonatal and pediatric critical care services, care management services, transitional care management services, 'incident to' services, split/shared E/M services, and reimbursement issues. Focusing on auditing the office medical record and providing a step-by-step guide to chart auditing.
Students will evaluate and manage audit case study exercises presented as would be done in the office setting for primary care, orthopedics, gastroenterology, pulmonology, general surgery, psychiatry, dermatology, oncology, and cardiology. They will also evaluate and manage audit case study exercises as they would in a hospital setting for primary care, orthopedics, gastroenterology, pulmonology, general surgery, oncology, and cardiology.
The course also concentrates on the surgical medical record, discussing coding based on surgical practice standards, surgery coding rules, CPT global surgery package, CMS surgical package, National Correct Coding Initiative (NCCI), separate procedures, X modifiers, scope procedures vs. open procedures, diagnostic services vs. therapeutic services, add-on codes, stand-alone codes, indented codes, starting the surgical audit process, auditing exercises, and key terms. They will explore auditing diagnostic radiology services, including diagnostic reporting categories, anatomy of a radiology report, diagnosis coding guidelines, starting the radiology audit, and auditing physical therapy services.
By completing this course, students will gain a comprehensive understanding of auditing evaluation and management services, office medical records, surgical medical records, and diagnostic radiology and physical therapy services, equipping them with the necessary knowledge and skills to effectively audit and assess these areas. Students will also have the background for the AAPC Certified Professional Medical Auditor (CPMA) examination.
