Medical Record Auditor

A guide to improving clinical documentation in a changing health environment

The fourth edition of this trusted resource helps a practice uncover where payment may be slowing or missing while ensuring compliance with payer rules and coding policy. Readers will come to understand how to identify overcoding and undercoding, improve documentation, and develop compliance improvement programs.

This publication will allow readers to:

• Analyze and review documentation guidelines and elements for each level of service Understand the medical record review process
• Comprehend how to properly audit the medical record
• Analyze and report results of an audit
• Develop mechanisms for reporting and educating staff on proper reporting
• Prepare for credentialing exams

Features and Benefits

• Chapter dedicated to clinical documentation improvement
• Case studies, featuring scenarios across nine different specialties for the office and hospital
• Checkpoint exercises and chapter-ending quizzes
• Audit cases, including surgery and radiology
• Tips on auditing and documentation
• Glossary of related terminology
• Downloadable user-friendly tools, including audit tools, audit exercises with case studies and answer keys, and an extensive PowerPoint presentation

Target Audience

Coding professionals, medical record auditors, academic and organizational educators, medical insurance specialists, clinical document improvement specialists, medical staff, practice administrators, consultants, independent billing and reimbursement personnel, physicians and physician leaders in practice and hospital settings