This tool provides questions to consider when performing audits of an 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? Are medical records reviewed for missing signatures, orders, etc.? If yes, what control measures ensure that the missing items are obtained?