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Medical Record Documentation Audit & Coding Analysis

Improve the compliance and financial health of your practice with medical record documentation audit and coding analysis.

The regulatory compliance requirements for coding, billing and documentation are complex, but we can assist you in identifying any potential problems and educating your providers and staff on accurately documenting and coding the services rendered to your patients.

Our approach

Our medical record reviews follow structured methodologies performed by certified professional coders and/or certified professional medical auditors to identify opportunities for improvement. A typical documentation and coding audit includes:

  • Analysis of clinical medical record documentation and coding analysis to ensure quality, improvement in patient care and carrier compliance
  • Individual provider coding accuracy reports
  • Evaluation of appropriate CPT, ICD-10-CM, HCPCS codes and modifier use
  • Analysis of encounter forms/charge tickets and insurer Explanations of Benefit (EOBs)
  • Review of claim denial management process
  • Provider and staff education and training
  • Preceptor documentation analysis with special attention to "Physicians at Teaching Hospitals" requirements

Our solutions

Our team of highly skilled, certified coders and auditors work collaboratively with you and your staff to identify and resolve coding issues before they can impact your compliance risk or bottom line.

Meet The Rehmann Team

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