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Documentation & Coding Compliance Audits


What is a coding compliance audit

What is a documentation and coding compliance audit?


A documentation and healthcare coding compliance audit is a comprehensive examination of a healthcare provider's medical documentation and coding practices to ensure adherence to regulatory guidelines, industry standards, and legal requirements. The purpose of such audits is to assess the accuracy, completeness, and compliance of medical records, coding procedures, and billing practices.


During the audit, trained professionals, often certified coders or compliance experts, review a sample of medical records, coding assignments, and associated documentation. They evaluate whether the healthcare provider's practices align with established coding principles, documentation guidelines, and applicable laws such as those set by government health agencies or private insurers.


The audit aims to identify any discrepancies, errors, or potential areas of non-compliance in the medical documentation and coding processes. Common areas of focus include proper code assignment, documentation specificity, compliance with coding conventions, and adherence to billing regulations.


The findings from a documentation and healthcare coding compliance audit can be used to enhance the accuracy of coding, improve documentation practices, mitigate risks of non-compliance, and ensure that healthcare providers are billing appropriately for the services rendered. Regular audits contribute to maintaining the integrity of healthcare data, reducing billing errors, and fostering compliance within the dynamic landscape of healthcare regulations.


How can ProCode Compliance Solutions help?

Our talented team of certified professional coders and medical auditors are experienced experts in the industry and cover all specialties. We match your reviewer with your specialty. Our documentation and coding audit approach follows a structured methodology designed to identify existing and potential coding and documentation issues that may impact revenue and/or compliance risks.

What we offer:

  • Documentation & Coding chart reviews

  • Pre-billing documentation & coding validation services

  • Prospective & retrospective audits

  • RAT STATS statistically valid sampling

  • Kovel & attorney client privilege engagement

In addition to conducting documentation and coding audits we provide one on one, and group, post audit provider education.

Our certified training experts have over 34 years’ experience effectively helping providers and staff understand how to practically meet the documentation guidelines in their day to day workflow. Our training is designed to be flexible and tailored based on your organizational needs and identified areas for targeted improvement. Once your audit is complete, we will work with you to evaluate appropriate training recommendations and the most cost effective method for your organization. Training can be delivered in a variety of methods depending on your preferences and budget.




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