This sample questionnaire can be utilized when performing an audit of a healthcare organization's medical records, coding and billing compliance processes.
Sample questions include: Are there specific policies and procedures in place to address medical documentation, coding and billing methodologies? Does the medical records department have an internal quality control program? If yes, how often is a review performed? What methods are currently utilized to document information in medical charts? Does the staff document results promptly in the charts? Are physician, hospital records and any ancillary medical care notes used for coding and submission of claims?