• AHAP Inc.

Quarterly Clinical Chart Review

Since most patient visits require an E/M code, Evaluation, and Management (E/M) codes are at the core of most physician practices and FQHCs. Qualified health professionals can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services.


With current modifications, Physicians, and other qualified health professionals (QHP) are able to code visits based solely on medical decision making (MDM), or solely on total time. History and exam components will no longer be necessary to support coding levels. Although history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing high-quality care.


Majority of private practices, and FQHCs, code assignment is based on the documentation by patient’s provider or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis. In other healthcare systems and hospital groups, the coding is performed by a certified medical coder.


Establishing Accuracy


It’s inevitable that errors occur, coding and billing mistakes in medical practices are common. Medical coding errors lead to higher claim denials, loss of revenue, and federal penalties, fines. That is why it’s vital for medical practices, and FQHCs to establish an oversight, audit and procedures that work to ensure accurate coding and billing.


Providers need to provide oversight in the billing and coding processes of their practices, whether they hire a credentialed in-house coder or choose to outsource the process. At a minimum, in house coders, billers, and providers should be trained annually on updates to CPT codes and other regulatory changes.


Audit Process


With the numerous changes that happen each year in healthcare and the subsequent risks that are presented, we recommend conducting a quarterly audits review of randomly chosen encounters and cases by a qualified and credentialed coding and billing staff. If your facility does not have an internal qualified reviewer, an independent consultant should be utilized.


Once an audit had been completed and issues are identified, a plan of action should be put in place to discuss appropriate actions to resolve errors noted and/or provide necessary education to the appropriate staff. Also, follow up audits should be considered, particularly if a higher level of errors is identified.

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