What is Medical Auditing? How it can be Performed?

Medical auditing entails conducting internal or external reviews of coding accuracy, policies, and procedures to ensure you are running an efficient and hopefully liability-free operation. Quality health care is based on accurate and complete clinical documentation in the medical record. The best way to improve your clinical documentation and the livelihood of your health care organization is through medical record audits. They are necessary to determine areas that require improvements and corrections.

The goals of an audit are to provide efficient and better delivery of care and to improve the financial health of your medical provider. Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by physician documentation. Once areas of weakness are revealed through an audit, you can present the audit findings and identify opportunities for training in your health care organization.

There are many reasons to perform medical audits:

  • To determine outliers before large payers find them in their claims software and request an internal audit.
  • To protect against fraudulent claims and billing activity
  • To reveal whether there is a variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
  • To help identify and correct problem areas before insurance or government payers challenge inappropriate coding
  • To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door
  • To remedy under-coding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures
  • To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
  • To stop the use of out-dated or incorrect codes for procedures
  • To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness

Auditing medical records can be a time-consuming process, but the benefits far outweigh the inconvenience. Depending on the objective, medical record audits can be performed either by an external agency or by staff within an organization. Audits conducted by a third party are generally to review compliance, and internal audits are usually performed to evaluate current treatment processes and measure the quality of care.

Medical records can be audited in the following easy steps:

  1. Choose the Focus of Audit

In general, the purpose of your audit should be to identify the clinical practices that are inconsistent or in need of improvement. The audit process should be Specific; Measurable based on the data available in the records; Important to the efficacy of your hospital and the care of your patients.

  1. Define Measurement Criteria

After you’ve identified the focus of your medical records audit, determine the specific measurement criteria for the review. Then, conclude which factors will decide whether or not these criteria are met. Performing a literature review can help expedite the process, since using methods already proven to be successful eliminates the need to develop your own standards for measurement. Literature reviews can also provide benchmarks for comparison.

  1. Determine Which Records to Review

In order to choose which records to include the audit, you must identify the precise patient population to be evaluated. Consider age, gender, clinical status, and treatment regimen, and be sure everyone involved in the audit knows exactly what determines whether a patient is included or excluded.

  1. Decide Sample Size

Completing an audit of every chart which meets your inclusion criteria is usually not feasible, so a good rule of thumb is to choose approximately 10 percent of the eligible charts to review. Statistical significance is heavily impacted by the sample size-if not enough records are audited, the variables will be too numerous and the audit results will have limited application.

  1. Develop Recordkeeping Tools

How you plan to collect and analyze the results of the audit will dictate the type of recordkeeping tools you create for example, will you record data electronically or with a paper-based system? The important thing is to organize the results in such a way that allows for evaluating individual records as well as aggregate data. Be deliberate about which data is recorded-this affects the types of analyses you can perform and the future usability of your discoveries.

  1. Gather Data

Coordinate the details of the audit: date and time to be performed; the number of charts to be pulled; the individuals involved; etc. Enlist the assistance of the medical records manager to help procure the charts and ensure HIPAA compliance. Then, perform the audit and collect the data.

  1. Summarize Your Findings

This step is crucial since disorganized or irrelevant data can result in an inability to use the audit results to enact change. Reflect on how the findings will be used and summarize the data in the way which will be most impactful.

  1. Analyze the Data and Implement Appropriate Changes

Review the findings of the audit and identify the opportunities for improvement. For example, if you see certain patient comfort solutions—such as applying a topical anesthetic before minor procedures—being used inconsistently, you can add them to the standard protocol. You can also take advantage of existing benchmarks to help guide your decisions.

Auditing medical records may seem tedious, but the data contained within these charts can be extremely valuable for improving hospital efficiency and ensuring patient satisfaction. It’s important to use all of the resources at your disposal to provide the best possible experience for your patients.


What is medical auditing?

Auditing Medical Records in 8 Easy Steps