What is Medical Auditing?

A medical auditor is a coder capable of reviewing medical documentation and the assigned procedure and diagnosis codes to determine if those coding assignments are appropriate. This determination is based on ethical coding guidelines and the application of CMS/AMA Documentation Guidelines.

Medical Auditor Job Description:
Medical Auditor performs necessary operations relating to the audits of medical records to identify discrepancies, in accordance with established procedures. Provides medical resource information to determine the accuracy of claims. Prepares necessary forms and proper documentation required performing audits and contracting issues. Identifies discrepancies in charges and provides educational support for problem areas. Communicates with hospital departments regarding discrepancies between charges and documentation in Medical Records. Perform medical audits to verify that billed charges match the documentation found in the medical record. All audit efforts are performed to ensure accurate reimbursement. Medical auditors serve as a resource on charge appropriateness and/or charge documentation issues. Providers need to do RAC audits and deal with payer denials. Physicians have regular audits done to be compliant with documentation and coding to improve revenue cycle. Ensuring medical necessity, correct coding and compliance with regulatory issues, a medical audit focuses on many areas of a practice. A medical auditor should have good understanding of the following:

Compliance and Regulatory Guideline Knowledge
Coding Concepts
Scope and Statistical Sampling Methodologies
Medical Record Auditing Skills and Abstraction Ability
Quality Assurance and Risk Analysis
Communication of Results and Findings
The Medical Record

Medical Auditing Certifications:
Certified Professional Medical Auditor (CPMA) from AAPC
AAMAS also provides CMAS certification

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