What we look for
- Missing or vague diagnoses that limit coding specificity
- Medical decision making or time that doesn't support the billed E/M level
- Medical necessity gaps for procedures, tests and referrals
- Incomplete signatures, dates and authentication
- Copy-forward and cloned notes that create compliance risk
- Chronic conditions not documented with status and plan
Chart audits vs. documentation reviews
A chart audit checks whether billed codes match the record. A documentation review looks one step earlier, at whether the record itself is complete enough to support accurate coding. Most practices benefit from both, and we can combine them in one engagement.
What you receive
- Provider-level documentation scorecards
- Examples of compliant documentation for common gaps
- A prioritized improvement plan
- Optional follow-up audit to measure progress
Frequently Asked Questions
How often should we audit documentation?
Many practices audit at least once a year, and more often for new providers, new services or after a payer review.
Will providers get individual feedback?
Yes. Findings are reported by provider with specific, practical examples so each clinician knows what to adjust.